N.J. Admin. Code § 10:142-9.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:142-9.2 - Adverse agency actions and appeal rights

(a) Determinations on denial of participant-directed services and/or involuntary disenrollment from the program shall be the responsibility of the Division, pursuant to N.J.A.C. 10:142-8.2, for all participants whether enrolled in managed care or in Medicaid fee-for-services.

1. Determinations involving a need for personal care services or level of benefits and award of services, involving reduction in hours, denial of benefits due to non-need, or denial of request for increased benefits, shall be the responsibility of the managed care organization (MCO) for participants enrolled in managed care.

(b) An applicant or participant may request a fair hearing pursuant to N.J.A.C. 10:142-9.3, on any adverse action, whether initiated by the managed care organization (MCO) or the Division pursuant to (a)1 above.

(c) Written notice (or other acceptable electronic communication in lieu of a written notice) shall be issued to the applicant or participant at least 20 days prior to initiation of an adverse action, by the agency rendering the decision, except in situations of involuntary disenrollment due to non-compliance stated in N.J.A.C. 10:142-8.2(c).

(d) The written notice pursuant to (c) above, shall indicate the reason(s) for the action to be taken, citing the basis for the decision, and language that affords the applicant or participant a right to appeal, through a fair hearing, pursuant to N.J.A.C. 10:142-9.3. The notice may also provide participants the ability to pursue the matter in dispute through a Division administrative review process as described in N.J.A.C. 10:142-9.1, as an alternative to a fair hearing.

(e) In addition to appeal rights afforded under (b) above, MCOs shall offer participants enrolled under managed care internal appeal rights that are available as a member of each respective plan, on any adverse action under (a) above. If a participant elects an internal appeal offered through an MCO, and a final decision is rendered on the matter in dispute, the MCO shall inform the Division of the outcome regarding any changes in scope, frequency, and/or amount of services to determine the impact on the budget allocation and cash management plan.

(f) A participant request for a fair hearing as described in (b) above, to dispute an involuntary disenrollment due to non-compliance with program requirements as described in N.J.A.C. 10:142-8.2(a) and (c) shall be denied.

N.J. Admin. Code § 10:142-9.2

Adopted by 49 N.J.R. 3993(a), effective 12/18/2017