Current through Register Vol. 56, No. 18, September 16, 2024
(a) The purpose of
this section is to define areas of responsibility and establish basic
principles and procedures in those collection activities in which the Division
of Medical Assistance and Health Services (DMAHS), the Division of Family
Development (DFD) and/or a county welfare agency (CWA) may be involved. It is
intended that maximum conservation of public funds be effected without
duplication of effort. It is recognized that certain situations may fall into
more than one of the following categories. Any such matter will be processed in
accordance with the provisions of the first occurring applicable
category.
(b) The following pertain
to incorrectly granted assistance (cash and/or medical assistance):
1. In instances involving incorrect
eligibility for medical assistance, whether or not in combination with cash
assistance, the CWA shall determine the period(s) of ineligibility and
ascertain from DMAHS the amount of medical assistance incorrectly granted. The
CWA shall then attempt recovery of medical assistance incorrectly granted
either by administrative collection, or by way of restitution in a criminal or
disorderly persons proceeding.
i. Recoveries
or attempts at recoveries can be made from those persons specified in
30:4D-7i.
2. When recovery cannot be obtained by these
methods in a case generated by the Internal Revenue Service (IRS) unearned
income component of the Income and Eligibility Verification System (IEVS), the
case shall be referred by the CWA to DMAHS for possible initiation of recovery
proceedings.
3. When, in any other
case not generated by IEVS, recovery cannot be obtained by these methods, the
CWA is authorized, after securing DMAHS approval, to initiate recovery
proceedings as DMAHS' agent. If the CWA does not initiate such recovery
proceedings, it shall refer the case to DMAHS for possible initiation of
recovery proceedings.
4. When
collection occurs in a case involving both cash assistance and medical
assistance, the CWA shall, in the absence of court instruction to the contrary,
apply the proceeds to the repayment of cash assistance and the reimbursement of
DMAHS for medical assistance. The reimbursement shall be made payable to the
Treasurer, State of New Jersey, which shall then reimburse the CWA in the
amount of 25 percent of the gross recovery on a periodic basis to be determined
by DMAHS.
5. When a CWA recovers
only for medical assistance improperly granted, the CWA shall remit the
proceeds to DMAHS. The reimbursement shall be made payable to the Treasurer,
State of New Jersey, who will then reimburse the CWA in the amount of 25
percent of the gross recovery on a periodic basis to be determined by
DMAHS.
6. When any CWA action,
whether alone or in combination with DMAHS, results in a recovery of improperly
granted medical assistance from a case generated by the Internal Revenue
Service (IRS) unearned income component of the IEVS match, all funds recovered
shall be remitted to DMAHS payable to the Treasurer, State of New Jersey, which
shall then reimburse the CWA in the amount of 25 percent of the gross recovery
on a periodic basis to be determined by DMAHS.
(c) The following pertain to third-party
liability claims in tort actions:
1. Whenever
either a CWA or DMAHS learns of a situation in any case in which the other may
have a claim, it will notify the other.
2. Unless the individual case circumstances
intervene, the first claim after settlement or judgment is for any payments by
New Jersey Medicaid or NJ FamilyCare program arising from the occurrence,
notwithstanding any CWA claim for recovery of cash assistance. The next claim
is that which the CWA may assert in accordance with an agreement to repay or
similar document. The DMAHS and the CWA will, insofar as their controls allow,
maintain priority of payment in the above order.
(d) The following pertain to liquidation of
potential resources:
1. The CWA will
participate in the liquidation of potential resources according to the Program
requirements under which eligibility has been established, regardless of
whether cash assistance is being granted. Notification of the potential
resource to be liquidated shall be forwarded to DHSS, enabling it to seek a
voluntary contribution. Sale of real property to which title is held by a CWA
is subject to DFD approval in all instances regardless of the proposed
distribution of the proceeds.
2.
All funds arising from the liquidation of resources and which, by action of
law, regulation, or agreement with the owner, fall under the jurisdiction of
either a CWA or DHSS for distribution will, insofar as possible, be allocated
as follows:
i. Proceeds will be first applied
to the cash costs of liquidation, such as advertising costs and filing fees,
but not including costs, such as CWA staff time, supplies, counsel fees or
overhead.
ii. Proceeds will be next
applied to any claims superior to that of the CWA (for example,
taxes).
iii. Proceeds will be next
applied to any funds owing to and collectible by the CWA.
iv. Any residue remaining after the above
payments are allocated would, in the absence of circumstances to the contrary,
be the property of the client and thereby subject to (d)3 below.
3. All funds properly belonging to
a beneficiary free of any agency claim are to be remitted to the beneficiary as
promptly as possible or otherwise disbursed at the beneficiary's instruction.
The CWA will promptly reevaluate eligibility following such distribution,
taking into consideration any voluntary repayment to the New Jersey Medicaid or
NJ FamilyCare program.
(e) The following pertains to recovery from
estates of deceased beneficiaries:
1. The CWA
shall normally undertake recovery activity as agent for DMAHS in any case in
which the CWA is or will be undertaking activities on its own account. However,
in those cases where the recovery of medical assistance is possible and where
the entire CWA claim is for burial expenses only, DMAHS shall initiate recovery
activity inclusive of CWA burial costs. DMAHS may, in certain cases, assume
direct jurisdiction in recovery of its claim concurrent with CWA activity.
DMAHS shall make the CWA aware of its activity in such cases.
2. CWA recoveries and distribution shall be
in accord with the following procedures:
i.
From the proceeds of liquidation, the CWA shall first recover the amount
necessary to satisfy its own claim, including costs of liquidation and the
claims of other New Jersey CWAs. The CWA shall recover funds from the clearing
account in the order in which the funds were received in the clearing account.
If any part of any remaining surplus has been received from the proceeds of
assigned life insurance for which there was a named beneficiary other than the
client's estate, that surplus or the policy benefit, whichever is less, is the
property of the beneficiary and should be so directed.
ii. All other surplus funds are part of (or
the entire) the client's estate and are payable to the legally designated
representative of the estate. If the representative of the estate is unknown or
if no representative has been appointed and there are no known next of kin, the
CWA shall forward to the DMAHS an amount not to exceed the amount of the proper
medical assistance claim as determined by communication with the Administrator,
Bureau of Administrative Control, DMAHS. Any remaining funds will escheat to
the State of New Jersey.
iii. When
there are known next of kin, the CWA shall request the next of kin to take
appropriate legal action to be appointed administrator if the amount to be
disbursed is greater than the claim of the New Jersey Medicaid or NJ FamilyCare
program. If the claim of the New Jersey Medicaid or NJ FamilyCare program will
equal or exceed the estate, the CWA shall request the next of kin to sign a
consent to transfer his or her rights to the New Jersey Medicaid or NJ
FamilyCare program and, upon receipt of such signed consent, the CWA shall
forward the funds to DMAHS.
iv.
When the next of kin will not sign a consent to transfer his or her right to
the Medicaid Agent and DMAHS and will not file to become the administrator, the
CWA may, at its option, arrange for someone to file to become administrator or
the CWA may refer the information to DMAHS for action.
v. In any questions or dispute among two or
more claimants on surplus funds, the CWA shall withhold payment pending
resolution by mutual consent of all claimants or by court order.
3. The Medicaid Agent or DMAHS
recoveries and distribution shall be in accordance with the following
procedures:
i. DMAHS shall undertake recovery
activity in medical assistance payment cases in which no CWA shall be
submitting a claim. However, should information from the CWA be necessary to
such DMAHS activity, the CWA shall communicate with DMAHS, supplying such
material as may be required.
ii. In
cases in which DMAHS is acting for a CWA in collection of burial expenses,
DMAHS shall accord payment of the burial claim priority over its own
recovery.
(f)
The CWA may at any time accept an offer of voluntary repayment, either on its
own behalf or on behalf of the New Jersey Medicaid or NJ FamilyCare program, up
to but not in excess of the amount of assistance granted. To any inquiry as to
amount granted, the CWA shall supply the appropriate information, identifying
the respective amounts granted by the CWA and the Medicaid Agent or DMAHS. In
the absence of instruction from the payer, the CWA will reimburse cash
assistance first and then remit any balance to DHSS.
1. Compromise settlements of medical
assistance are subject to DHSS approval.
(g) Regarding compromise settlements:
1. Compromise settlements of cash assistance
are subject to DFD approval.
2.
Compromise settlements of medical assistance are subject to DMAHS
approval.
(h) This
section shall apply to all pending and future recovery cases, except that:
1. The 25 percent incentive payments provided
for in (b)4 and 5 above shall apply to all non-IEVS incorrect payment
recoveries received by the CWA on or after July 1, 1993.
2. Paragraph (b)6 above applies to all
IEVS-related recoveries received on or after July 1, 1989 by either DMAHS or
the CWA, whichever agency is handling the recovery.