New Jersey Administrative Code

A complete summary report of pertinent information shall be made for each contact with a beneficiary, which shall clearly state the basis for any recommendation for termination of Medicaid. A new redetermination form shall be completed for each redetermination. Notes N.J. Admin. …

(a) Each applicant shall receive timely and adequate written notice of any change in Medicaid eligibility status in accordance with N.J.A.C. 10:69-6. (b) If the notice of intention to terminate Medicaid eligibility is related to identification of possible fraud, beneficiaries are…

(a) The client shall be informed periodically (at least once every 12 months) of his or her continuing obligation to furnish accurate and timely information to the CWA concerning changes in income or other circumstances that may affect the receipt of benefits. The applicant shall…

(a) Extended Medicaid benefits shall be provided to former AFDC-related Medicaid families in accordance with the provisions of this section for a period of 24 months beginning with the month in which the family no longer would have otherwise been eligible for AFDC-related Medicai…

(a) A newborn child shall be added to the AFDC-related Medicaid case effective with the date of birth, provided that the CWA is notified within one year of that date. (b) The date of change for adding other members added to an eligible unit shall be the first day of the month the…

(a) Redetermination is a review of factors affecting AFDC-related Medicaid eligibility, including, but not limited to, continued parental deprivation, or changes in income. At the redetermination, the parent(s) shall complete an application for continuation for Medicaid. If a red…

(a) At the option of the beneficiary, the face-to-face interview may be conducted. The eligibility worker shall assist the beneficiary in the completion of the application form, providing explanation as necessary. If the beneficiary cannot read, the contents of the form shall be …

(a) The eligibility worker should be alert to the development of medical or mental problems that may affect the adequate functioning of the parent. Such evidence shall be submitted to the Disability Review Section for special review. (b) If it is the finding of the CWA that the p…

Notes N.J. Admin. Code § 10:69-5.5 Reserved by 49 N.J.R. 3729(a), effective 12/4/2017

(a) Since eligibility in AFDC-C is based on the fact that the needy child has been deprived of parental support or care by reason of the death, continued absence from home, or mental or physical incapacity of a natural or adoptive parent, it is necessary to reevaluate these facto…

In AFDC-C, when eligibility is based on the absence of one parent and the remaining parent marries or remarries, such marriage or remarriage does not in and of itself terminate eligibility but does require prompt redetermination of financial need and eligible unit composition in …

(a) When a parent becomes absent from the home and continuous absence is established (N.J.A.C. 10:69-2.9(e) ), the AFDC-F case shall be transferred to the AFDC-C segment. No interruption of Medicaid shall result if AFDC-C eligibility begins with the absence. (b) When a parent bec…

(a) Each legally responsible relative's capacity to support shall be reevaluated at least once in each 12-month period and adjustments made as indicated (see N.J.A.C. 10:69-3.31(d) ). (b) Each legally responsible relative shall be contacted unless it can be verified that the rela…

The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise. "Adequate notice" means a written notice that meets the requirements of N.J.A.C. 10:69-6.2(d). "Administrative hearings" are hearings con…

The CWA shall provide the applicant/beneficiary and/or his or her authorized representative opportunity to review the entire case file or documents and records to be used in the administrative hearing. Such materials shall be made available at a reasonable time before the schedul…

(a) Representation shall be pursuant to N.J.A.C. 1:10B-5.1. (b) The CWA representative must have knowledge of the matter at issue and must be able to present the agency case, supplying the ALJ with that information needed to substantiate the agency action. If the CWA representati…

(a) Prior to transmittal to OAL, if a party desires that a hearing request be withdrawn, that party shall notify the CWA or DMAHS in writing of the withdrawal request. DMAHS shall in turn acknowledge, in writing, receipt of the withdrawal request. No CWA shall deny or dismiss a r…

Any adjournment requested by an applicant or beneficiary and granted by the OAL may not operate to extend the deadlines for a final decision and final agency implementation of the final decision. Notes N.J. Admin. Code § 10:69-6.13

(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 or…

(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 …

(a) It is the right of every applicant or beneficiary adversely affected by an action by a CWA to be afforded a fair hearing in a manner established by the rules in this subchapter and by the Uniform Administrative Procedure Rules, N.J.A.C. 1:1. These rules have been established …

(a) Upon receipt of a timely request for a fair hearing, Medicaid coverage shall be continued until a written decision is rendered, unless: 1. A determination is made at the hearing by the ALJ that the sole issue is one of State or Federal law or policy, or change in State or Fed…

(a) Each request for a fair hearing shall be registered by the Bureau of Administrative Review and Appeals (BARA) on the date the request is received. (b) Requests initially received in BARA shall be transmitted by telephone to the CWA on the date received. (c) BARA shall transmi…

(a) The Office of Administrative Law shall schedule the hearing and shall send any necessary notices to the parties. (b) The hearing shall be conducted by an administrative law judge who shall issue an initial decision. Notes N.J. Admin. Code § 10:69-6.5

(a) Requests on matters which constitute a contested case (as defined by N.J.A.C. N.J.S.A. 1:1-1 and consistent with case law) shall be handled in accordance with the Department of Human Services (DHS) rules on "Administrative Hearings and Administrative Reviews" at N.J.A.C. 10:6…

(a) Prompt and courteous attention shall be given to all complaints, whether or not such complaints constitute requests for fair hearing and whether or not they are directed to the CWA or the Division of Medical Assistance and Health Services. All complaints received shall be ack…

(a) An applicant or beneficiary has a right to request a fair hearing which relates to an agency action or lack of action within 20 days of such action or lack of action. (b) If the request for a fair hearing relates to an agency action or lack of action that occurred more than 2…

(a) When a request is made for a fair hearing within 15 days from the date of mailing of a notice of termination, Medicaid coverage shall be continued until the scheduled date of the administrative hearing or the date of the administrative review unless the beneficiary waives suc…

(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 i…

Any statistical data or other information not including any names or personal information may be released. Notes N.J. Admin. Code § 10:69-7.10

(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;…

(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 id…

(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) 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 …

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. Notes N.J. Admin. Code § 10:6…

(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 indic…

(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 …

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. Notes N.J. Admi…

(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…

(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 informat…

(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 professi…

(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 entitlem…

(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 poin…

(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 ser…

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. Notes N.J. Admin. Code § 10:69-8.7

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. Notes N.J. Admin. Code § 10:69-9.1

Any statistical data or other information not including any names or personal information may be released. Notes N.J. Admin. Code § 10:69-9.10