N.J. Admin. Code § 10:167-5.4 - Exceptions from normal standards

(a) There may be exceptional cases where the processing of an eligibility application cannot be completed within a normal 30-day period. Where substantially reliable evidence either of eligibility or ineligibility is still lacking; the application shall be continued in pending status. In each such case, however, the Department shall be prepared to demonstrate that the delay resulted from one of the following:

1. Circumstances wholly within the applicant's control; or

2. A determination to afford to an applicant whose proof of eligibility has been inconclusive, further opportunity to develop additional evidence of eligibility before final action on this application; or

3. An administrative or other emergency that could not reasonably have been avoided; or

4. Circumstances wholly outside the control of both the applicant and the PAAD program.

(b) A PAAD applicant, who meets all the PAAD eligibility criteria, can reasonably expect to receive his or her PAAD eligibility card within 30 days from the date that a complete and valid Eligibility Application is received by PAAD.

(c) In the event that mailing of the eligibility card is delayed, the PAAD program shall reimburse the PAAD beneficiary directly for the cost (minus a PAAD co-payment per prescription) of all prescription drugs purchased by the person on or after the 30th day after his or her properly completed application was received by the PAAD program, subject to the following conditions:

1. The eligibility application or renewal application must have been fully and properly completed.

2. The PAAD beneficiary must submit a prescription claim form and proof of purchase for each eligible prescription to the PAAD program. The claim form must be completed by a participating New Jersey pharmacy, or by a licensed mail order pharmacy service program where the prescription is delivered to a New Jersey address.

3. No direct reimbursement will be made for any drugs purchased after the date when the beneficiary receives his eligibility identification card.

Notes

N.J. Admin. Code § 10:167-5.4

Amended by R.1993 d.155, effective 4/5/1993.
See: 24 N.J.R. 4328(a), 25 N.J.R. 1514(a).
Amended by R.1993 d.368, effective 7/19/1993.
See: 24 N.J.R. 4329(a), 25 N.J.R. 3216(a).
See: 29 N.J.R. 5280(a), 30 N.J.R. 1314(b).
Amended by R.2009 d.16, effective 1/5/2009.
See: 40 N.J.R. 4479(a), 41 N.J.R. 221(a). Amended by 48 N.J.R. 1366(b), effective 7/5/2016