New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL
Subchapter 5 - APPLICATION PROCESS
Section 10:167B-5.6 - Responsibilities in the application renewal process

Universal Citation: NJ Admin Code 10:167B-5.6

Current through Register Vol. 56, No. 18, September 16, 2024

(a) The 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. Automatically mail reapplication forms approximately four months prior to the eligibility expiration date; and

5. Copy eligibility application and supporting documents onto microfilm and retain the microfilm for audit purposes.

(b) The applicant or beneficiary has the responsibility to:

1. Complete the Senior Gold eligibility application or the renewal application form legibly and accurately by:
i. Answering all questions fully;

ii. Presenting all necessary evidentiary documents, including a copy of any third party health insurance cards and/or Medicare prescription benefits coverage cards;

iii. Reading the certification and authorization statement;

iv. Signing or marking the application or renewal application; and

v. Obtaining the signature or mark of the spouse (if married) and the signature of the preparer (if applicable) on the application or renewal application;

2. Assist the Department by securing evidence that corroborates statements when necessary;

3. Agree to a review by the Department or its agent, if randomly selected for review. Senior Gold eligibility may be terminated if the beneficiary refuses to cooperate with a quality control request;

4. Assign benefits to the State of New Jersey when prescription drug costs are covered in part by any other plan of assistance or insurance;

5. Reapply for eligibility on forms mailed by the Department at least 45 days prior to his or her eligibility expiration date if he or she wishes to renew Senior Gold eligibility;

6. Complete his or her renewal application by interview if selected as part of a sample group by Senior Gold. Senior Gold eligibility will not be renewed if the beneficiary refuses to complete the eligibility review;

7. If the application mailed by the Program is lost in the mail, misplaced or not received due to the applicant's change of address, it is the applicant's responsibility to contact the Program for a new application;

8. Notify the Program whenever any one of the following occurs:
i. His or her marital status changes; or

ii. He or she moves anywhere within the State of New Jersey, in which case, he or she shall submit proof of new address;

9. Immediately return his or her eligibility card to the Program whenever becoming ineligible due to one of the following:
i. He or she moves out of the State of New Jersey;

ii. He or she becomes eligible for Medicaid, PAAD, or any other plan of assistance or insurance that fully covers pharmaceutical services;

iii. His or her annual income increases to an amount which exceeds the legal limit;

iv. He or she was determined eligible based on his or her disability and he or she stops receiving Social Security Disability benefits; or

v. He or she failed to submit information to confirm eligibility if scheduled recovery payments are in arrears; and

10. Repay the State of New Jersey, upon request, for the cost of benefits incorrectly paid on his or her behalf. Failure to fully repay the State for incorrectly paid benefits could cause the suspension of his or her Senior Gold benefits in the future, as well as possible withholding of all or some of his or her rebates or refunds which may be due him or her from the State of New Jersey.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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