N.J. Admin. Code § 10:69-2.15

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

Section 10:69-2.15 - Notice of approval, disapproval, and pending status and other information to client

(a) If immediate need is not apparent and a decision of approval or disapproval is not reached within 30 days of application, the CWA shall notify the applicant in writing of this fact and the reason for the delay. If the lack of decision is due to circumstances within the control and knowledge of the applicant, the CWA shall remind the applicant of the steps he or she must take to enable the CWA to make a decision. This notice shall include a sentence in Spanish cautioning the client that it relates to his or her eligibility for AFDC-related Medicaid and if he or she does not understand the notice he or she should contact the CWA. Translations to languages other than Spanish may be prepared based on knowledge of the population served by the CWA.

(b) When a decision is reached, the applicant shall be notified in writing of this decision (approved or disapproved).

(c) If the application is denied, the notice of disapproval shall meet the requirements in N.J.A.C. 10:69-6. In addition, for an applicant whose application has been denied for any reason other than death, the notification shall include:

1. An explicit statement of the reason for ineligibility;

2. Information about requesting a fair hearing to appeal the decision;

3. Advice concerning the family's right to reapply whenever they believe that their circumstances have changed such that the stated reasons for ineligibility no longer exist; and

4. Information about the Supplemental Nutrition Assistance Program (SNAP) and other potentially available services.

(d) If the application is approved, the client shall be advised in writing:

1. Of the effective date of Medicaid eligibility;

2. That an advance statement shall be sent at least 10 calendar days prior to implementation of any adverse decision affecting future eligibility;

3. Of the client's right to a fair hearing;

4. Of the client's rights and responsibilities under the program for which he or she has been approved (see 10:69-2.2(a)3 and 2.3(a));

5. Of his or her obligation to report all relevant changes in circumstances, including but not limited to, family size, income, employment, and change in parent-person status;

6. Of the use of the Health Benefits Identification (HBID) Card and/or Health Benefits Emergency Services Letter (see N.J.A.C. 10:49-2.15); and

7. That he or she may qualify for a number of additional services which the eligibility worker will describe briefly and explain where to apply for these services.

(e) Notification to a beneficiary whose application has been approved following change of residence from another county shall include a statement that:

1. The beneficiary has been found to be a resident of this county for purposes of Medicaid coverage; and

2. Future determination of eligibility will be made by this CWA rather than by the CWA of the county of previous residence.

(f) When the coverage is based on an earnings projection (see N.J.A.C. 10:69-10.25) , a notice shall be sent advising the client that the coverage will be terminated after the initial calendar month of eligibility unless he or she provides wage verification as required. Such notice shall specify the date by which the verification must be received.

(g) Clients shall also be advised in writing that if he or she is dissatisfied with any action or inaction of the CWA, he or she may request a hearing. He or she shall be informed of the steps that are to be followed in making such a request in accordance with the requirements in N.J.A.C. 10:69-6.

(h) A client shall be provided a copy of the written application with any attachments upon request.

(i) In any case initially referred by, or known to be receiving assistance or service from, a public health or welfare agency, social service, legal services or other interested agencies, notice of disposition of the case or any aspect in which that organization has been involved shall be sent to such agency with the consent of the client in the following manner:

1. If, after thorough discussion of the medical coverage potentially available and the application requirements, the person definitely declines to apply, the interested agency shall be promptly informed.

2. If the person applies and the application is approved, the interested agency shall be notified as promptly as possible, including the date of Medicaid eligibility.

3. If the person applies and the application is denied, dismissed or withdrawn, the agency shall be promptly informed.

4. The interested agency shall be kept informed of any developments in a case so long as the issue involved is the same or related to the issue about which the agency has expressed interest unless the client withdraws his or her consent.

N.J. Admin. Code § 10:69-2.15

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