N.J. Admin. Code § 10:69-9.23

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

Section 10:69-9.23 - Basis for recovery of incorrectly paid benefits for purposes other than for fraud, or third-party liability

(a) Incorrectly paid benefits means Medicaid coverage received by or for an eligible unit for which they were otherwise not entitled. The overpayment was caused by reasons other than fraud or third party liability.

(b) Incorrectly paid benefits may occur through administrative error; failure of a client to inform the CWA or designee pursuant to Federal regulation of a change in income or circumstances; or when the client has received continued Medicaid coverage but has been found ineligible to receive such Medicaid coverage or part of such coverage by the fair hearing decision.

(c) The CWA or designee pursuant to Federal regulation shall seek recovery of all overpayments regardless of fault including AFDC-related Medicaid payments caused by administrative action or inaction. The CWA or designee pursuant to Federal regulation shall recover such incorrectly paid benefits in accordance with procedures set forth in this chapter.

(d) Medicaid incorrectly paid benefits to an eligible unit, all members of which are no longer receiving AFDC-related Medicaid program, shall be recovered by the CWA through a court of appropriate jurisdiction if the family does not voluntarily repay the overpayment.

(e) In locating former beneficiaries who have outstanding incorrectly paid benefits, the CWA shall use appropriate data sources such as unemployment insurance files, the Division of Taxation, the New Jersey Motor Vehicle Commission, Bendex, and other data sources relating to current or former beneficiaries.

(f) For incorrectly paid benefits occurring prior to October 1, 1981, the CWA shall recover only if the overpayment resulted from willful withholding of information by the beneficiary.

(g) The CWA may waive recovery of AFDC-related Medicaid incorrectly paid benefits if the eligible unit is no longer receiving AFDC-related Medicaid and the amount overpaid is less than $ 35.00. When the amount of the incorrectly paid benefit to an eligible unit no longer receiving AFDC-related Medicaid is $ 35.00 or more, the CWA may waive the recovery of the incorrectly paid benefit, if after a reasonable effort to recover the incorrectly paid benefits, the CWA determines it is no longer cost effective to continue recovery efforts. Recovery of overpayments due to fraud may not be waived regardless of the amount of incorrectly paid benefit.

1. Reasonable efforts to recover an incorrectly paid benefits include, at a minimum, written notification of the amount of and reason for the incorrectly paid benefit and that repayment is required.

2. All circumstances concerning a waiver of recovery must be fully documented in the case record.

(h) The CWA shall not initiate or continue recovery of any outstanding incorrectly paid benefits of Medicaid coverage that occurred in another state.

N.J. Admin. Code § 10:69-9.23

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