New Jersey Administrative Code

(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…

(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 conti…

(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 misrepresenta…

(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 Se…

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 Divisi…

(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 …

(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 socia…

(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, …

(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, …

(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 N.J.A.C. 10:69-9.8. The agency shall take s…

(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 er…

The CWA shall provide all reports as requested by the Division of Medical Assistance and Health Services (DMAHS). Notes N.J. Admin. Code § 10:69-9.3 Amended by 49 N.J.R. 3729(a), effective 12/4/2017

(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 instanc…

(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 …

Funeral and burial expenses may be provided for AFDC-related Medicaid beneficiaries (all segments) as regulated in N.J.A.C. 10:90-8. Notes N.J. Admin. Code § 10:69-9.6

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…

(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. Info…

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…

Notes N.J. Admin. Code § 10:7-1.1 Amended by R.2003 d.96, effective 3/3/2003. See: 34 N.J.R. 3181(a), 35 N.J.R. 1276(a). In (c), substituted "2002" for "1999". Amended by R.2007 d.71, effective 3/5/2007. See: 38 N.J.R. 1978(a), 39 N.J.R. 772(b). In (c), substituted "2006" for "20…

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise. "Agency" means a Division, institution, facility, or organizational unit within the DHS. "Amended order" means a superior court order changi…

(a) The county adjuster shall be responsible for commitment, admission, review, and discharge of persons receiving DMHAS services, including those receiving services from county psychiatric facilities. (b) In regard to voluntary admissions, the county adjuster shall: 1. Arrange f…

(a) The county of admission of a DDD client shall be the county where the individual resided prior to admission to a DDD facility or community residential placement (b) No court order of settlement or support shall be issued to DDD clients or their LRRs. (c) The Department of Hum…

The county adjuster shall make all client records available to the Department, its designated agents, or contractors. Notes N.J. Admin. Code § 10:7-3.3

The county adjuster shall cooperate fully with the Department, its designated agents, or contractors in the determination of settlement, and the review of the client's or LRR's financial ability to pay for the services provided. Notes N.J. Admin. Code § 10:7-3.4

(a) The county adjuster, at the discretion of the court, shall act as referee to conduct investigations to determine each client's legal settlement and the client's/LRR's financial ability to pay for the cost of care and maintenance. This investigation shall be a thorough and sys…

(a) The county adjuster shall determine the applicant's family size in accordance with this section. Family size for an adult applicant includes the applicant, spouse, any minor children whom he or she supports, and adults for whom the applicant is legally responsible. The family…

(a) The county adjuster is responsible for accounting activities regarding clients/LRRs of DMHAS and the county psychiatric facilities with respect to the State billing for clients with county settlement, the county billing for clients with State or no settlement, and billing and…

(a) DDD through its agencies and designated agents shall file all liens against the real and personal property of every State and county settlement DDD client admitted to services, whether or not a client has any known property. The only exception is that liens for Medicaid clien…

(a) The following apply only to actions on non-Medicaid liens or debt. Liens filed by DMAHS shall only be compromised, settled, subordinated or released by DMAHS. (b) Regarding State agencies, the county adjuster shall forward all requests for compromises, settlements, discharges…

(a) The county adjuster shall meet the appropriate records retention requirements specified by the State in the county adjuster's record retention schedule, by the county governing body and/or by the AOC. To the extent that any record contains personal health information, the cou…

The county adjuster shall assure compliance with Federal and State law and these regulations or appropriate sanctions may be applied. A county's failure to submit required legal documents, financial reports and payments within the time periods specified may result in the impositi…

(a) The governing body of each county shall be afforded an opportunity to appeal any section imposed. Appeals will not be expected to resolve issues that have policy implications or broader applicability. There are two levels of appeal available: 1. Level 1: A request for a Level…

(a) The Medically Needy Program, enacted by P.L. 1985, Chapter 371, extends limited Medicaid program benefits to certain groups of medically needy persons whose income and/or resources exceeds the standards for the Medicaid program but are within the standards for the Medically N…

(a) Purpose of the regulations contained within this chapter is to: 1. Set forth eligibility for the Medically Needy Program; 2. Establish policy for calculating spend-down liability for persons whose income exceeds the Medically Needy Income Level; and 3. Specify the rights and …

The Medically Needy Program is administered by the county welfare agencies under the supervision of the Division of Medical Assistance and Health Services of the Department of Human Services. Notes N.J. Admin. Code § 10:70-1.3

(a) The following principles of administration apply in the Medically Needy Program. 1. Any individual who believes he or she is eligible shall be afforded an opportunity to make application (or reapplication) for the Medically Needy Program without delay. 2. Program applicants o…

(a) No member, officer, or employee of a county board of social services 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…

(a) All materials distributed to applicants or eligible persons must: 1. Directly relate to the administration of the Medicaid program; 2. Have no political implications; 3. Contain names only of individuals directly connected with the administration of the Medicaid program; and …

(a) Title VI of the Federal Civil Rights Act of 1964 ( Public Law 88-352), the Americans with Disabilities Act, P.L. 101-336, and Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the ground of race, color, national origin, or handicap in the administratio…

(a) Any person who applies for the Medically Needy Program, by virtue of the application for benefits, is deemed to have assigned to the Commissioner of the Department of Human Services any rights to support for the purpose of medical care as determined by a court or administrati…

(a) Application for the Medically Needy Program shall be accomplished by the completion and signing of Form PA-1G for SSI-related cases and Form PA-1J for AFDC-related cases, as well as, any addenda to those forms as prescribed by the Division of Medical Assistance and Health Ser…

A personal face-to-face interview with the program applicant(s) or the authorized agent is required as part of the process of determining program eligibility. Notes N.J. Admin. Code § 10:70-2.2

(a) Collateral verification is the use of third-party information (both documentary and nondocumentary) from agencies or individuals other than members of the applicant's household to substantiate the accuracy of statements made on the application and during the interview.1. Prog…

(a) When individuals move permanently to another county within the State, responsibility for the case shall be transferred in accordance with the provisions of this section. The case transfer shall be accomplished in a manner so not to adversely affect the rights of any individua…

(a) Eligibility for the Medically Needy Program shall be redetermined as follows: 1. When required, on the basis of information the county board of social services (CBOSS) has obtained previously about anticipated changes in the case situation, or when additional information is n…

(a) Except for persons receiving Social Security benefits as a result of disability or blindness, the factors of disability and blindness will be redetermined at intervals established by the Division of Medical Assistance and Health Services, Disability Review Section. (b) Any pe…

(a) Upon a determination of eligibility for the Medically Needy Program, members of the eligibility group (or their authorized agent) have on-going responsibility for the reporting of changes in circumstances and the provision of information as delineated at N.J.A.C. 10:70-2.1(c)…