Current through Register Vol. 56, No. 18, September 16, 2024
(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 pursuant to Federal regulations,
45 CFR
205.10, and the New Jersey Administrative
Procedure Act,
N.J.S.A.
52:14B-1 et seq.
(b) The CWA shall promptly notify the
beneficiary in writing of any agency decision affecting that client. The term
"agency decision" refers to a decision made by the CWA and includes any
decision made by the CWA. In the case of a client who cannot be located, notice
shall be sent to his or her last known address.
(c) Agency action which adversely affects an
applicant or beneficiary includes:
1. Any
action, inaction, refusal of action, or unduly delayed action with respect to
program eligibility, including, but not limited to, denial or termination of
benefits; and
2. When the complete
processing of an application is delayed beyond 30 days, the applicant is to be
notified of this fact and the reason(s) for the delay on or before the
expiration of such period (see
10:69-2.14 and 2.15).
(d) The written notice of adverse
action shall, at a minimum, include the following:
1. The action the agency intends to
take;
2. The reasons for the
intended agency action;
3. The
specific regulations supporting such action;
4. An explanation of the individual's right
to request a fair hearing;
5. An
explanation of how to request a fair hearing;
6. The time limits on requesting a
hearing;
7. An explanation of the
right to examine evidence;
8. An
explanation of the circumstances under which continued Medicaid coverage is
continued if a hearing is requested;
9. An explanation of the requirement to repay
Medicaid coverage received during the period pending the hearing, if the agency
action is upheld;
10. A sentence in
Spanish cautioning the client that the notice relates to a change in Medicaid
coverage and if he or she does not understand the notice, he or she should
contact the CWA; and
11. The name,
address and phone number of the nearest legal services office where
available.
(e) Where an
agency decision results in an adverse action, there will be no termination of
the AFDC-Medicaid related coverage until at least 10 days after the mailing
date of the notice, except in situations described in (f) below.
(f) Timely notice may be dispensed with but
adequate notice shall be sent not later than the effective date of action when:
1. The agency has factual information
confirming the death of a beneficiary;
2. The agency receives a clear written
statement signed by a beneficiary that he or she no longer wishes continued
Medicaid coverage, or that gives information which requires termination, and
the beneficiary has indicated, in writing, that he or she understands that this
must be the consequence of supplying such information;
3. The beneficiary has been admitted or
committed to an institution, that does not qualify for Federal financial
participation under the State plan;
4. The beneficiary has been placed in a
nursing facility, intermediate care facility or long-term hospital;
5. The claimant's whereabouts are unknown and
agency mail has been returned by the post office indicating no known forwarding
address. The Health Benefits Identification (HBID) Card or HBID Emergency
Services Letter must, however, be made available to the beneficiary if his or
her whereabouts become known during the medical coverage period, unless (f)5i
below applies.
i. The claimant moves
out-of-State, with apparent intent to remain permanently absent from New
Jersey;
6. A beneficiary
has been accepted for medical assistance in another state and that fact has
been established by the CWA previously providing Medicaid coverage;
7. An AFDC child is removed from the home as
a result of a judicial determination, or voluntarily placed in foster care by
his or her legal guardian; or
8.
The application for Medicaid coverage is being denied.
