Current through Register Vol. 56, No. 18, September 16, 2024
(a) Involuntary disenrollment shall be a result of non-compliance with
program rules and procedures, or an inability to self-direct and manage program services, which may include,
but are not limited to, the following circumstances:
1. Failure to submit
information necessary to determine or reaffirm program eligibility;
2. Documented abuse or misuse of program services or employees as verified
by the Division, with or without the provision of technical assistance and support from the consultant and/or
financial management agent;
3. Failure of the participant to
manage their own care needs, which results in placing the health or welfare of a participant or an employee
at increased risk, as determined by the consultant, representative, vendor fiscal employer agent, or through
substantiated allocations of abuse, neglect, or exploitation by Adult Protective Services (APS);
4. Duplication of program services through other service programs or
funding sources as verified by the Division;
5. Verified, willful
or knowing falsification of employee timesheets, vendor invoices, or other required program
documents;
6. Participant is no longer eligible for Medicaid
benefits;
7. Commission of other acts identified as program fraud
or abuse of program services that have been substantiated;
8.
Failure to notify a consultant of admission to a medical facility;
9. Failure to participate in mandated required home visits pursuant to
N.J.A.C. 10:142-2.2(a)13;
10. Failure to submit timesheets and
invoices/bills in accordance with prescribed time frames set forth by the VF/EA;
11. Documented non-response by the participant to attempts to make contact
by the Division or agents thereof in the administration of the program;
12. Documented unwillingness to accept assignment of a mandated
representative in accordance with requirements under N.J.A.C. 10:142-2.2(c) and 3.3(e);
13. Documented inability to comply with participant responsibilities as
identified under N.J.A.C. 10:142-2.2; or
14. Failure to report
changes in program contact information to the Division, or agents thereof, pursuant to N.J.A.C.
10:142-2.2(a)16.
(b) All decisions to involuntarily
disenroll an individual from participant directed services shall be made by the Division. In determining an
involuntary disenrollment based on action(s) as described under (a) above, the Division shall consider the
specifics of the situation, on a case-by-case basis, including, but not limited to, the following:
1. The severity of the situation;
2. Any recurrences or patterns in the situation; and
3. The effort and willingness demonstrated by the participant to resolve
the issue or to mitigate the problem.
(c) Individuals
who are involuntarily disenrolled shall have participant directed services terminated immediately.
Participants shall receive subsequent written notice from the Division following any determination pursuant
to (b) above. The notice must include the reason/justification for the action taken, and include information
to enable access to the Division's administrative review process pursuant to N.J.A.C. 10:142-9.1.
1. The Division, in collaboration with the MCO, will assist the participant
in accessing Medicaid State Plan PCA services through traditional provider agencies, following an involuntary
disenrollment.
2. The Division shall assist the participant with
the transition process as described in (c)1 above, but cannot guarantee the acceptance by a PCA provider
agency or the time it may take for the transition to be completed.
(d) In situations in which it has been identified that the participant is
unable to direct and manage services as described in (a) above, an option may be afforded to designate the
use of a representative, where appropriate, to maintain enrollment in the program.
