reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 165 - PLANNING AND SERVICE AREAS AND AREA AGENCIES ON AGING › Subchapter 2 - DESIGNATION AND REVOCATION OF PSAs AND AREA AGENCIES ON AGING › Section 10:165-2.1 - Requirements for PSAs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				State Division shall divide the State into distinct PSAs, based on the
				following factors:
1. The geographic
				distribution of older individuals in the State;
2. The incidence of the need for supportive
				services, nutrition services, multi-purpose senior centers, and legal
				assistance;
3. The distribution of
				older individuals who have greatest social and economic need (with particular
				attention to low-income minority individuals);
4. The distribution of older individuals who
				are American Indians;
5. The
				distribution of resources available to provide the items set forth in (a)2
				above;
6. The boundaries of
				existing areas within the State which were drawn for the planning or
				administration of supportive services programs, if any; and
7. The location of units of general purpose
				local government within the State.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 165 - PLANNING AND SERVICE AREAS AND AREA AGENCIES ON AGING › Subchapter 2 - DESIGNATION AND REVOCATION OF PSAs AND AREA AGENCIES ON AGING › Section 10:165-2.2 - Designation as a Planning and Service Area (PSA)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A PSA designation shall be subject to the
				following minimum standards:
1. The PSA shall
				encompass a unit of general purpose local government with a population of
				100,000 or more; or
2. The PSA
				shall encompass any region within the State recognized for purposes of
				area-wide health planning that includes one or more units of general purpose
				local government.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 165 - PLANNING AND SERVICE AREAS AND AREA AGENCIES ON AGING › Subchapter 2 - DESIGNATION AND REVOCATION OF PSAs AND AREA AGENCIES ON AGING › Section 10:165-2.3 - Designation of Area Agencies on Aging

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The State Division shall designate one
				Area Agency on Aging for each PSA.
(b) An Area Agency on Aging shall be one of
				the following:
1. An established office of
				aging operating within a PSA;
2.
				Any office or agency of a unit of general purpose local government or
				combination of units of general purpose local government, which is designated
				to function only for the purpose of serving as an Area Agency on Aging by the
				chief elected executive(s) of the general purpose local government;
				or
3. Any public or nonprofit
				private agency in a PSA, or any separate organizational unit of a public or
				private nonprofit agency within a PSA.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 165 - PLANNING AND SERVICE AREAS AND AREA AGENCIES ON AGING › Subchapter 2 - DESIGNATION AND REVOCATION OF PSAs AND AREA AGENCIES ON AGING › Section 10:165-2.4 - Procedures for revocation of an Area Agency on Aging designation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The State
				Division shall not revoke a designation unless notice and a public hearing has
				been held in accordance with
				N.J.A.C.
				10:165-1.3.
(b) In addition to providing notice in
				accordance with (a) above, the State Division shall provide personal written
				notice to the designated Area Agency on Aging whose designation the State
				Division intends to revoke at least 60 days prior to the intended action,
				specifying in the notice the reason(s) for the revocation, which shall not be
				inconsistent with
				N.J.A.C.
				10:165-2.5.
(c) Upon receipt of the notice of intent to
				revoke through the 30th day following the date on which the State Division
				provides written notice on the matter, an agency shall have a right to make an
				appeal in accordance with
				N.J.A.C.
				10:165-2.3(j) and (k).
1. Appeals to the Assistant Secretary on
				Aging may be made on the basis of the facts and merits of the matter that is
				the subject of the action or proceeding, or on procedural grounds.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 165 - PLANNING AND SERVICE AREAS AND AREA AGENCIES ON AGING › Subchapter 2 - DESIGNATION AND REVOCATION OF PSAs AND AREA AGENCIES ON AGING › Section 10:165-2.5 - Basis for revocation of an Area Agency on Aging designation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The State
				Division may revoke the status of an agency or organization as the Area Agency
				on Aging when the State Division determines that:
1. The agency or organization has not
				complied with Federal and State requirements for Area Agencies on Aging, as
				delineated in
				42 U.S.C. §
											3001 et seq., 42 C.F.R. 1321,
				N.J.S.A.
				40:23-6.38 and 6.44, and this
				chapter;
2. The agency fails to
				perform functions mandated by Federal and State law and regulation;
3. The agency's Area Plan or an Area Plan
				amendment is not approved;
4. The
				agency has failed to comply with any provision of the Act, Federal regulations,
				or State laws in the provision or administration of an approved Area
				Plan;
5. The agency's activities
				are inconsistent with the statutory mission prescribed in the Act or conflict
				with the requirement in the Act that the agency function only as an Area Agency
				on Aging;
6. The State Division
				determines, through fiscal, programmatic, or on-site assessments, that the
				agency lacks the authority, qualified staff and/or capacity to carry out the
				functions of an Area Agency on Aging as set out in the Act and this
				chapter:
7. The agency fails to
				respond to a written notice of noncompliance, or fails to implement an approved
				plan of corrective action within the timeframe specified by the State Division
				in such notice or approved plan;
8.
				The State Division determines that the agency is using resources allocated to
				it by the State Division in violation of this chapter, the Act and/or Federal
				regulations;
9. The agency
				voluntarily terminates its grant or resigns as an Area Agency on Aging;
				or
10. The State Division has
				redefined the geographic boundaries of the PSA.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 1 - INTRODUCTION › Section 10:167-1.1 - Purpose and intent

Current through Register Vol. 56, No. 14, July 15, 2024
(a) It is intended
				that Pharmaceutical Assistance to the Aged and Disabled (PAAD) shall extend
				assistance to certain persons whose level of income disqualifies them for
				medical assistance under the New Jersey Medical Assistance and Health Services
				Act, but who have significant needs for prescribed drugs and/or insulin,
				insulin needles, insulin syringes, and/or certain diabetic materials and are
				unable to fully meet the cost of such items.
(b) This manual has been developed as a
				statement of policy and procedures and is applicable only to eligibility for
				the PAAD Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 1 - INTRODUCTION › Section 10:167-1.2 - Legal authority

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The New Jersey
				Program of Pharmaceutical Assistance to the Aged and Disabled (PAAD) was
				established by Chapter 194, Laws of 1975, as amended by:
1. Chapter 194, Laws of 1975, effective
				August 21, 1975. Amended by Chapter 312, Laws of 1975, effective February 19,
				1976;
2. Chapter 268, Laws of 1977,
				effective January 1, 1978;
3.
				Chapter 171, Laws of 1978, effective December 22, 1978;
4. Chapter 27, Laws of 1979, effective March
				1, 1979;
5. Chapter 499, Laws of
				1981, effective March 1, 1982;
6.
				Chapter 209, Laws of 1985, effective August 1, 1985;
7. Chapter 221, Laws of 1987, effective July
				29, 1987 and retroactive to December 31, 1986;
8. Chapter 16, Laws of 1989, effective
				February 1, 1989; and
9. Chapter
				84, Laws of 1991, effective April 3, 1991 and retroactive to January 1, 1991;
				and
10. Chapter 30, Laws of 1992,
				effective June 29, 1992.
11.
				Chapter 3, Laws of 1993, effective January 13, 1993 and retroactive to January
				1, 1993;
12. Chapter 27, Laws of
				1995, effective February 15, 1995, retroactive to January 1, 1995;
13. Chapter 323, Laws of 1995, effective
				April 4, 1996;
14. Reorganization
				Plan No. 001-1996; and
15. Chapter
				281, Laws of 2003, effective January 1, 2005.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 3 - ADMINISTRATIVE ORGANIZATION › Section 10:167-3.1 - Department of Human Services

Current through Register Vol. 56, No. 14, July 15, 2024
The Department of Human Services is the administrative unit
				  of the State government which has control over the administration of PAAD.
				  Under the terms of the PAAD law, this Department is responsible for the general
				  policies governing administration of PAAD, and for effecting the issuance of
				  rules, regulations and procedures in accordance with the Administrative
				  Procedure Act for implementing the statutory provisions.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 3 - ADMINISTRATIVE ORGANIZATION › Section 10:167-3.2 - Division of Medical Assistance and Health Services

Current through Register Vol. 56, No. 14, July 15, 2024
The Division of Medical Assistance and Health Services is
				  the administrative unit of the Department of Human Services that performs
				  certain administrative functions for, or in conjunction with, the Department.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 3 - ADMINISTRATIVE ORGANIZATION › Section 10:167-3.3 - Pharmaceutical Assistance to the Aged and Disabled Program

Current through Register Vol. 56, No. 14, July 15, 2024
The Pharmaceutical Assistance to the Aged and Disabled is
				  the program in the Department which has the direct responsibility for the
				  processing of eligibility applications from applicants.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167-4.1 - Statutory limitations

Current through Register Vol. 56, No. 14, July 15, 2024
By statute, the Pharmaceutical Assistance to the Aged and
				  Disabled Program is limited to payment or reimbursement to pharmacies for the
				  reasonable cost of prescription drugs for eligible persons, which exceeds the
				  PAAD co-pay and to Medicare Part D authorized prescription drug plans for the
				  premiums associated with PAAD beneficiaries.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167-4.2 - Principles of reimbursement to participating pharmacies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Reimbursement
				for PAAD prescriptions shall be made only to pharmacies located in New Jersey
				except as indicated in (b)1 below and operating under a valid permit from the
				Board of Pharmacy of the State of New Jersey. In order to become an approved
				provider, such a pharmacy must file an application and agreement of
				participation, which must be approved by the Division of Medical Assistance and
				Health Services of the Department of Human Services. The application shall
				contain the pharmacy's NSC Supplier Number issued by the National Supplier
				Clearinghouse (NSC) or other appropriate agent of the Centers for Medicare and
				Medicaid Services (CMS) or a statement that the pharmacy has applied for an NSC
				Supplier Number to enroll as a Medicare Part B supplier. A copy of one of the
				proofs of enrollment listed in
				10:167A-1.3(c)2 
				shall be attached to the application. The pharmacy shall also complete and
				return the Electronic Data Interchange (EDI) Enrollment Form attached to the
				application.
(b) No reimbursement
				shall be made to an unlicensed pharmacy or to a pharmacy located in another
				state or country, except as follows:
1. The
				Department shall have the authority to coordinate benefits with any voluntary
				mail-order prescription drug program or specialty pharmacy in a Medicare Part D
				plan provider network, or a mail order prescription drug program required by a
				PAAD beneficiary's primary payer.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167-4.3 - Interchangeable drug products

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Whenever PAAD
				is the primary payer and any interchangeable drug product is available for the
				prescription written, the PAAD Program shall reimburse for multisource generic
				drugs without prior authorization, but not for multisource brand name drugs
				without prior authorization.
(b) If
				the prescriber does not specify to the contrary, the PAAD beneficiary has two
				options:
1. To purchase an interchangeable
				drug product which is equal to or less than the maximum allowable cost, at the
				PAAD co-pay; or
2. To purchase the
				prescribed drug product, which is higher in cost than the maximum allowable
				cost and pay in full.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167-4.4 - Beneficiary co-payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No direct
				payment to beneficiaries shall be made under the PAAD Program, except as noted
				in (b) below. The beneficiary must pay the pharmacy a nonrefundable PAAD co-pay
				per prescription or per purchase of insulin, insulin syringes, insulin needles
				or syringes and needles for injectable medicines used for the treatment of
				multiple sclerosis.
(b) In the
				event that a PAAD beneficiary receives his or her eligibility identification
				card later than 30 days from the date that his or her complete and valid
				Eligibility Application was received by the PAAD program, he or she may be
				eligible to receive direct reimbursement for prescription drugs purchased. See
10:167-5.4
for
				details.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167-4.5 - Medicare Part D Prescription Drug Plan premium payments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Department shall pay Medicare Part D premiums to the PDP on behalf of PAAD
				beneficiaries in accordance with the Fiscal Year 2016 Appropriations Act, P.L.
				2015, c. 63, approved June 26, 2015, as amended and supplemented by subsequent
				State appropriations acts.
1. If the PDP is a
				Medicare-authorized prescription drug plan associated with a Medicare-managed
				care plan (MA-PD), the PAAD program shall pay an amount towards the
				prescription portion of the premium up to and including the benchmark amount
				set for New Jersey by CMS for the current benefit year pursuant to
				42 CFR
				423.780(b)(2), as amended
				and supplemented, which is incorporated herein by reference.
2. If the PDP is an MA-PD and the premium
				cost is above the benchmark amount set for New Jersey by CMS, the PAAD
				beneficiary shall be responsible for any premium costs that are above the
				benchmark amount.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167-5.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
The application process includes all activity relating to a
				  request for eligibility determination. It begins with the receipt by the
				  Department of an eligibility application and continues in effect until there is
				  an official disposition of the request by the Department.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167-5.2 - Authorized agent

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In those
				instances where the applicant is incompetent or incapable of filing an
				eligibility application on his or her own behalf, the Department shall accept
				any one of the following listed in the order of priority, as an authorized
				agent for the purpose of initiating such application:
1. Power of attorney;
2. A close relative by blood or marriage,
				that is, parent, spouse, son, daughter, brother, sister;
3. A representative payee designated by the
				Social Security Administration;
4.
				A staff member of a public or private social service agency, of which the
				person is a client, who has been designated by the agency to so act;
5. A friend.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167-5.3 - Eligibility effective date

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The PAAD
				eligibility effective date for an initial PAAD applicant, who meets all of the
				PAAD eligibility criteria, is the date when processing of a valid and complete
				eligibility application is completed by the PAAD program.
(b) The PAAD program shall conduct periodic
				redeterminations of the eligibility of PAAD beneficiaries.
1. Those not requested to submit a renewal
				application for any given year shall be mailed an eligibility card for the year
				automatically.
2. PAAD shall
				request and review renewal applications to verify continued eligibility of
				certain beneficiaries on a case-by-case basis. Those beneficiaries required to
				renew shall be notified in writing and shall receive a renewal application from
				PAAD. At least 45 days prior to the expiration of PAAD benefits, the
				beneficiary shall submit a fully and accurately completed renewal application
				form, along with the required signature(s) and supporting documentation.
				However, if beneficiaries are late in submitting their renewal applications,
				but apply within 90 days after the expiration date, those beneficiaries who
				meet the PAAD eligibility criteria shall receive continuous PAAD benefits. If
				the renewal application is submitted more than 90 days after the expiration
				date, the eligibility effective date for eligible beneficiaries will be the
				date when a valid and completed renewal application is processed by the PAAD
				program. If the PAAD beneficiary is late in filing his or her renewal
				application by more than 90 days after the expiration date, the PAAD program
				shall not make reimbursement until the new eligibility period has been
				established.
3. For those
				beneficiaries submitting renewal applications, PAAD shall reassess eligibility.
				If PAAD determines that a beneficiary is eligible for the program, then PAAD
				shall mail a new eligibility card to the beneficiary. If PAAD determines that a
				beneficiary is ineligible for the program, then PAAD shall notify such person,
				in writing, and he or she shall be disenrolled from PAAD. The PAAD program
				shall not reimburse a beneficiary for the cost of prescription drugs purchased
				after he or she has been disenrolled from the program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167-5.4 - Exceptions from normal standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There may be
				exceptional cases where the processing of an eligibility application cannot be
				completed within a normal 30-day period. Where substantially reliable evidence
				either of eligibility or ineligibility is still lacking; the application shall
				be continued in pending status. In each such case, however, the Department
				shall be prepared to demonstrate that the delay resulted from one of the
				following:
1. Circumstances wholly within the
				applicant's control; or
2. A
				determination to afford to an applicant whose proof of eligibility has been
				inconclusive, further opportunity to develop additional evidence of eligibility
				before final action on this application; or
3. An administrative or other emergency that
				could not reasonably have been avoided; or
4. Circumstances wholly outside the control
				of both the applicant and the PAAD program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167-5.5 - Agency controls

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Commissioner shall establish operating policies within the Department to
				expedite the processing of applications and assure the maximum possible
				compliance with the standards set forth in this manual.
(b) The Department has the responsibility for
				reviewing a statistically valid representative sample of PAAD cases to assure
				that beneficiary eligibility is determined consistent with State law and
				eligibility regulations. A quality control review, of sample cases selected on
				a random basis, includes:
1. Analysis of the
				beneficiary's case record, including the application, which is maintained by
				the PAAD Program; and
2.
				Verification of eligibility factors and third party liability information
				through collateral contacts.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167-5.6 - Responsibilities in the application and renewal process

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				Pursuant to statutory authority, the Department establishes procedures on the
				application process consistent with law and supervises the operation with the
				policy and procedures so established.
(b) The Pharmaceutical Assistance to the Aged
				and Disabled Program has responsibility in the application process to:
1. Explain the purposes and eligibility
				requirements of the program and indicate the applicant's rights and
				responsibilities under its provisions;
2. Process applications and
				reapplications;
3. Issue
				eligibility cards to eligible persons and to notify ineligible persons
				promptly;
4. Mail reapplication
				forms prior to the eligibility expiration date when current information is
				necessary to verify continued eligibility;
5. Maintain the eligibility application and
				supporting documents for audit purposes; and
6. Gather information to determine
				eligibility for Lifeline programs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167-5.7 - Combined application for PAAD/Lifeline

Current through Register Vol. 56, No. 14, July 15, 2024
(a)
				There shall be only one application for those beneficiaries who apply for both
				PAAD and Lifeline.
1. A beneficiary may file
				one application for both programs on the same form.
2. If an applicant wishes to apply only for
				Lifeline, he or she shall use the PAAD eligibility application form. (See
10:167D-4.8
)
3. On reapplication for Lifeline, the
				applicant shall complete the PAAD renewal form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.1 - Age

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To be eligible
				for PAAD, the applicant shall be 65 years of age or older or shall be under 65
				and over 18 years of age and receive Social Security Title II disability
				benefits. Individuals under age 65 who receive disability benefits on behalf of
				someone other than themselves are ineligible. The applicant shall be able to
				document his or her age upon request by the Department. The Department will
				require that the applicant submit a photocopy of his or her certificate or
				other acceptable proof of age if over 65 years of age.
(b) The following are acceptable proofs of
				age:
1. Primary proof: The applicant is
				required to submit a photocopy of one of the following documents:
i. Birth certificate;
ii. Baptismal certificate;
iii. Bris certificate;
iv. Social Security records verifying age
				(can be obtained from local security office);
v. Railroad retirement letter (can be
				obtained from Railroad Retirement Board).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.2 - Income standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any single permanent resident of New
				Jersey who is 65 years of age or over or who is under 65 and over 18 years of
				age and is receiving Social Security Title II disability benefits must have an
				annual income of less than $ 28,769 to be eligible for PAAD.
(b) Any married permanent resident of New
				Jersey who is 65 years of age or over or who is under 65 and over 18 years of
				age and is receiving Social Security Title II disability benefits must have a
				combined (applicant and spouse) annual income of less than $ 35,270 to be
				eligible for PAAD.
1. An applicant and spouse
				shall be considered separate and eligibility determined under the single income
				standard when each maintains a separate residence and the applicant does not
				have access to the spouse's income.
i. Any
				support payment received by the applicant for the sole benefit of the applicant
				shall be considered as income for PAAD eligibility purposes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.3 - Citizenship

Current through Register Vol. 56, No. 14, July 15, 2024
A person shall not be required to be a citizen of the United
				  States in order to be eligible for PAAD.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.4 - Residence

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The statute
				provides that "any . . . resident of this State . . . shall be eligible for
				PAAD. 'Resident' means one legally domiciled within the State for a period of
				30 days immediately preceding the date of application for inclusion in the
				program. Mere seasonal or temporary residence within the State, of whatever
				duration, does not constitute domicile. Absence from this State for a period of
				12 months is prima facie evidence of abandonment of domicile. The burden of
				establishing legal domicile within the State is upon the applicant."
1. Interpretation: The term resident shall be
				interpreted to mean a person having his customary place of abode in New Jersey.
				The fact that an individual was or may have been motivated to move to New
				Jersey because of the availability of medical facilities does not, of itself,
				justify a finding that he has not established a residence in this State;
				however, such inquiry need not be made if an individual has been physically
				present in New Jersey for a period exceeding three months.
2. The applicant must be able to substantiate
				residence upon request by the Department and is required to submit photocopies
				of two documents showing evidence of current residence at the time of initial
				application.
3. The following are
				examples of sources of evidence of residence:
i. Motor vehicle records (for example, valid
				driver's license);
ii. Landlord's
				records and rent receipts;
iii.
				Public utility records and receipts (for example, electric bill);
iv. Personal property assessment
				records;
v. Records of business or
				professional people, such as doctors, department stores, etc.;
vi. Post office records;
vii. Records of social agencies, public or
				private;
viii. Employment records;
				and
ix. Social Security
				records.
4.
				Determination as to continued New Jersey residence of a person absent from this
				State shall be based upon contact with the applicant by a representative of the
				Department.
5. In reaching a
				decision as to continuing New Jersey residence of an absentee, the issue is
				whether the individual intends to return to New Jersey or remain indefinitely
				in the other jurisdiction. If a beneficiary leaves New Jersey with the intent
				to establish a place of abode elsewhere, he becomes ineligible under the PAAD
				program and must notify the Pharmaceutical Assistance to the Aged and Disabled
				program of the address and return the PAAD eligibility card.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.5 - Recipient of other assistance and pharmaceutical coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The State
				statute provides that any person shall be ineligible for PAAD if he/she is
				otherwise qualified for assistance under the Act of which the PAAD Act is a
				supplement (Chapter 413, Laws of 1968). This is interpreted to mean that a
				State resident 65 years of age or older cannot be eligible for PAAD when
				receiving Medicaid benefits.
(b)
				The State statute further provides that any otherwise eligible person whose
				prescription drug costs are wholly covered by any other plan of assistance or
				insurance shall be ineligible for PAAD.
(c) A PAAD applicant shall supply the PAAD
				Program with sufficient information for PAAD to apply for Medicare Part D
				coverage on behalf of the applicant.
(d) The applicant, having provided all the
				necessary information to the PAAD Program, shall be enrolled in a Medicare Part
				D plan, except in the following cases:
1. The
				applicant is in an employer prescription drug plan, where the employer accepts
				a subsidy from Medicare for continued coverage of the employee/retiree;
				or
2. The applicant is not eligible
				under Medicare Part D.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.6 - PAAD eligibility application and renewal application forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				eligibility application forms are available to applicants in central and local
				offices and other convenient locations throughout the State, on the
				Department's website at
www.state.nj.us/humanservices/doas/home/ap2.html
,
				and by writing to the New Jersey Department of Human Services, Pharmaceutical
				Assistance to the Aged and Disabled (PAAD), PO Box 715, Trenton, NJ
				08625-0715.
(b) Applicants shall
				apply, or renew their application, for PAAD and/or for Lifeline on forms
				approved by PAAD.
(c) The
				application forms specified by this section shall contain fields for the
				submission of the information required by
				10:167-6.1 through 6.9 to
				determine eligibility, and fields for applicants to approve the release of
				information in accordance with
				10:167-6.11.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.7 - Social Security account number

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Each applicant
				for PAAD benefits must include his or her Social Security Account Number (SSAN)
				on the application/reapplication form. The SSAN is a unique and verifiable
				number which is utilized to differentiate between persons with the same name.
				Married persons must also indicate the SSAN of their spouse.
(b) In the event that the applicant does not
				have a SSAN, a unique identifying number will be assigned by the PAAD program.
				This number will be used throughout the beneficiary's PAAD
				eligibility.
(c) Each applicant
				shall include a Medicare Health Insurance Claim number on the
				application/reapplication, if the applicant has been assigned one.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.8 - Certification

Current through Register Vol. 56, No. 14, July 15, 2024
The applicant for PAAD benefits must certify that all the
				  answers to the questions and items on the application/renewal application form
				  are true and accurate to the best of his/her knowledge. This certification must
				  be dated, signed or marked by the applicant and spouse (if married), and the
				  preparer of the form (if other than the applicant), before the
				  application/renewal application can be processed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.9 - Authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) By signing or
				marking the certification and authorization statement on an application or a
				renewal application form, an applicant or a reapplicant authorizes:
1. The Department to serve as the authorized
				representative of the applicant or reapplicant;
2. The Department to verify any information
				on the form by contacting the Social Security Administration, the Internal
				Revenue Service, the New Jersey Division of Taxation, employers and others as
				the need arises;
3. Assignment of
				benefits to the State of New Jersey if he/she or his/her spouse has any other
				plan of assistance or insurance that covers, at least in part, the cost of
				prescription drugs; and
4.
				Prescribing practitioners to release information concerning prescriptions which
				have been paid by the PAAD program, to the Department or any law enforcement
				authority of this State charged with the investigation or prosecution of
				violations of the criminal provisions of the "Pharmaceutical Assistance to the
				Aged and Disabled Act" or the criminal laws of this State.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.10 - Eligibility period

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A PAAD eligibility card is effective for
				the dates indicated on the card. PAAD shall automatically renew each
				beneficiary's eligibility card annually unless PAAD determines, in its sole
				discretion, that a beneficiary must submit current information by completing a
				renewal application. The PAAD beneficiary shall renew his or her eligibility in
				accordance with the provisions of
10:167-5.3(b)
.
(b) PAAD will notify the
				beneficiary if he or she must complete a renewal form. Renewal applications
				must be returned to the PAAD Program by the beneficiary at least 45 days prior
				to the expiration date to ensure continuous coverage.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167-6.12 - Appeal process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When PAAD
				determines that an application is ineligible for benefits, the applicant has
				the right to appeal the decision by submitting a written request for a fair
				hearing to Pharmaceutical Assistance to the Aged and Disabled, PO Box 715,
				Trenton, New Jersey 08625-0715, within 30 calendar days from the date of
				mailing of the notice of ineligibility. The document must clearly state the
				valid basis for such a request.
(b)
				PAAD will forward the hearing request, if determined to be a contested case, to
				the Office of Administrative Law which will schedule the hearing and notify all
				parties of the date, time and location of the hearing.
(c) The petitioner will have the burden of
				demonstrating that PAAD's determination deviates from the requirements and
				standards of the regulations and statute.
(d) When the PAAD beneficiary requests a fair
				hearing, he or she shall clearly indicate the existence of a disputed question
				of fact or law arising from the requirements and standards of the rules and
				statutes of the PAAD program. If the beneficiary fails to establish a contested
				case, the PAAD program shall deny the hearing request.
1. Hearings are not intended to be
				informational or to provide a forum for the expression of public sentiment on
				PAAD actions or policies.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 7 - RECOVERIES AND LIENS › Section 10:167-7.1 - Recoveries for benefits correctly paid

Current through Register Vol. 56, No. 14, July 15, 2024
Pursuant to P.L. 1983, C. 371, no encumbrance or recovery of
				  any kind shall be imposed or sought from the estate of a qualified applicant or
				  an eligible person after his death because of assistance paid, or to be paid,
				  on his behalf under the PAAD program, except for assistance incorrectly or
				  illegally paid, or for third party liability recovery sought under the New
				  Jersey Medical Assistance and Health Services Act ( P.L. 1968, C. 413, codified
				  as 30:4D-1 et seq.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 7 - RECOVERIES AND LIENS › Section 10:167-7.2 - Recoveries for benefits incorrectly paid

Current through Register Vol. 56, No. 14, July 15, 2024
(a) As provided in
				30:4D-1 et seq., the Department
				may take all necessary action to recover the cost of benefits incorrectly paid
				on behalf of a beneficiary.
1. The term
				"incorrect payment" includes, but is not limited to:
i. Payment made on behalf of a beneficiary
				whose drug costs are wholly covered by another source;
ii. Payment made on behalf of a beneficiary
				who is no longer eligible, or has been incorrectly determined to be eligible to
				receive benefits;
iii. Payment made
				as a result of fraud perpetrated by a beneficiary, his or her authorized agent
				and/or provider; and
iv. An
				unanticipated payment that makes a recipient ineligible for benefits, in which
				case the provisions of
				30:4D-21.4 shall apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 7 - RECOVERIES AND LIENS › Section 10:167-7.3 - Liens

Current through Register Vol. 56, No. 14, July 15, 2024
Provisions for the application of liens shall be consistent
				  with and conform to any provisions for liens as provided in
				  30:4D-1 et seq.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167 - PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED ELIGIBILITY MANUAL › Subchapter 7 - RECOVERIES AND LIENS › Section 10:167-7.4 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Any person violating any provision of the PAAD Act shall be
				  subject to the applicable civil and criminal penalties contained in the "New
				  Jersey Medical Assistance and Health Services Act" (30:4D-1 et seq.). In addition, any
				  eligible person who violates any provision of the PAAD Act shall be subject to
				  a suspension of their eligibility for one year for a first offense and
				  permanent revocation of their eligibility for a second offense.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter provides information about the provision of
				  pharmaceutical services under the PAAD program, which shall extend assistance
				  to certain persons whose level of income disqualifies them for medical
				  assistance under the Medical Assistance and Health Services Act, but who have
				  medical needs for prescribed drugs and/or insulin, insulin needles, insulin
				  syringes and syringes and needles for injectable medicines used in the
				  treatment of multiple sclerosis and are unable to fully meet the cost of such
				  items. For additional information regarding PAAD eligibility, see N.J.A.C.
				  10:167.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.3 - Participation of eligible providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A pharmacy,
				with a retail or institutional permit, may participate in the PAAD program as a
				provider of pharmaceutical services.
(b) To be approved as a provider of
				pharmaceutical services, the pharmacy shall:
1. Operate under a valid retail or
				institutional permit issued by the Board of Pharmacy of the State of New Jersey
				and be assigned a national provider identifier. A pharmacy operating under an
				out-of-State retail or institutional pharmacy permit may not participate as an
				approved provider in the PAAD program, except for a voluntary prescription drug
				mail-order program or specialty pharmacy in a Medicare Part D Plan or a mail
				order prescription drug program required by a PAAD beneficiary's primary payer
				and, which maintain a permit from the Board of Pharmacy of the State of New
				Jersey.
2. File an application and
				sign an agreement with the Department of Human Services (DHS), Division of
				Medical Assistance and Health Services (DMAHS) and maintain a Medicaid provider
				number issued by DMAHS.
i. Upon sale or other
				change of ownership of an approved pharmacy, the agreement is automatically
				terminated. To execute a new agreement to participate in the PAAD program, the
				new owner(s) shall apply to the Division, by contacting the Medicaid Provider
				Enrollment Unit (see N.J.A.C. 10:49, Administration Chapter, Enrollment
				Process) or the fiscal agent Provider Enrollment Unit.
3. To enroll as a Medicaid provider of
				pharmaceutical services, a pharmacy shall obtain a copy of the provider
				application on-line at
www.njmmis.com
or
				contact the Fiscal Agent Provider Enrollment Unit (see N.J.A.C. 10:51, Appendix
				D, Fiscal Agent Billing Supplement).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.4 - Reserved

Current through Register Vol. 56, No. 14, July 15, 2024
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.5 - Conditions for participation as a provider of pharmaceutical service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All participating pharmacies shall
				provide services within the scope of the permit issued by the Board of Pharmacy
				of the State of New Jersey. Prescriptions must be dispensed in compliance with
				all current existing Federal and State laws.
(b) All drugs must be prescribed.
1. "Prescribed drugs" means simple or
				compounded substances or mixtures of substances prescribed for the cure,
				mitigation, or prevention of disease, or for health maintenance that are:
i. Dispensed by licensed pharmacists in
				accordance with regulations promulgated by the New Jersey State Board of
				Pharmacy, N.J.A.C. 13:39; and additional prescription pricing in accordance
				with P.L. 1994, c.67, as revised by P.L. 1995, c.5 (see
				10:167A-1.15(b) 
				); and
ii. Dispensed by licensed
				pharmacists on the basis of a written, telephonic, or electronic prescription
				that is recorded and maintained in the pharmacist's records.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.6 - Program restrictions affecting payment for prescribed drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The choice
				of prescribed drugs shall be at the discretion of the prescriber within the
				limits of applicable laws. However, the prescriber's discretion is limited for
				certain drugs. Reimbursement may be denied if any of the following, or any of
				the requirements of this chapter are not met:
1. Prescription Drug Price and Quality
				Stabilization Act (N.J.S.A. 24:6E-1 et seq.) (see
				N.J.A.C.
				10:167A-1.21 ) and Non-Proprietary or generic
				dispensing (see
				N.J.A.C.
				10:167A-1.12 );
2. Federal regulations (
				42 CFR 447.500,
				512-516 ) that set the aggregate upper limits on payment for certain
				multi-source drugs if Federal Financial Participation (FFP) is to be made
				available. The limit applies to all "maximum allowable cost" drugs (see
				N.J.A.C.
				10:167A-1.7, Basis of payment); and
3. Drug Efficacy Study Implementation (DESI):
				"Less than effective drugs" subject to a Notice of Opportunity for Hearing
				(NOOH) by the Federal Food and Drug Administration (see 10:167A-1.22 ) and
				listing of DESI drugs in (N.J.A.C. 10:51, Appendix A).