Current through Register Vol. 56, No. 6, March 18, 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.
