N.J. Admin. Code § 10:69-6.3

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:69-6.3 - Responsibilities of the CWA in processing hearing requests

(a) Upon receipt of a timely request for a fair hearing, Medicaid coverage shall be continued until a written decision is rendered, unless:

1. A determination is made at the hearing by the ALJ that the sole issue is one of State or Federal law or policy, or change in State or Federal law, and not one of disputed facts; or

2. A change occurs which further affects beneficiary's eligibility while the first hearing decision is pending and the beneficiary fails to request an additional hearing after notice of this change within the time allowed.

(b) In the event of either (a)1 or 2 above, the beneficiary shall be promptly notified in writing that the proposed action will be implemented after the hearing while the decision is pending.

(c) Any incorrectly paid benefit resulting from continued Medicaid coverage is subject to recovery. In the event that agency action is sustained and a beneficiary has received incorrectly paid Medicaid benefit, solely due to continued eligibility, recovery shall be effected in accordance with procedures in 10:69-9.23.

(d) A beneficiary may waive his or her claim to Medicaid by submitting a written statement at the time the fair hearing is requested.

(e) To assure orderly and expeditious processing of complaints and hearing requests, each CWA shall designate a liaison between the county and State Division whose duties shall include, but not be limited to:

1. Informing the Bureau of Administrative Review and Appeals (BARA) by telephone on the same day an oral or written request for a hearing is received, providing the following information:

i. The case number and the applicant/beneficiary's name and address;

ii. The date the request received;

iii. The nature of contested action;

iv. The date of action; and

v. The reason for action;

2. Establishing a system to assure that every written request for a hearing received in the CWA office is stamped with the date of receipt and forwarded to BARA within one work day of the date;

3. Reviewing incoming requests for possible corrective action prior to hearing;

4. Identifying and arranging for participation of staff individuals who are essential to a hearing, and assembling all records relevant to a hearing and arranging for an interpreter when the client is non-English speaking;

5. Contacting the applicant/beneficiary or his or her legal or authorized representative not less than two days prior to a hearing to confirm attendance and arranging for transportation by agency staff and vehicles or otherwise at agency expense when no other reasonable means of transportation is available;

6. Submitting special reports on hearing requests prior to the hearing date, when requested by BARA;

7. Submitting reports on implementation of fair hearing decisions as soon as such action is taken when requested; and

8. Serving as the single individual in the CWA to be contacted regarding matters relating to hearings and the monitoring system.

(f) The CWA is responsible to inform the applicant/beneficiary who is requesting a hearing and elects to receive continued Medicaid that the ALJ may find him or her not entitled to all or a portion of the Medicaid coverage received during the pendency of the hearing and that, in such event, repayment may be required of the amount of benefits received from the effective date of the proposed adverse action to the date of the scheduled hearing.

1. The beneficiary shall also be advised that if he or she elects not to receive continued Medicaid coverage and the hearing decision is favorable to the client, Medicaid coverage shall be reinstated retroactive to when it was terminated.

N.J. Admin. Code § 10:69-6.3

Amended by 49 N.J.R. 3729(a), effective 12/4/2017