N.J. Admin. Code § 10:167-5.6 - Responsibilities in the application and renewal process

(a) Pursuant to statutory authority, the Department establishes procedures on the application process consistent with law and supervises the operation with the policy and procedures so established.

(b) The Pharmaceutical Assistance to the Aged and Disabled Program has responsibility in the application process to:

1. Explain the purposes and eligibility requirements of the program and indicate the applicant's rights and responsibilities under its provisions;

2. Process applications and reapplications;

3. Issue eligibility cards to eligible persons and to notify ineligible persons promptly;

4. Mail reapplication forms prior to the eligibility expiration date when current information is necessary to verify continued eligibility;

5. Maintain the eligibility application and supporting documents for audit purposes; and

6. Gather information to determine eligibility for Lifeline programs.

(c) The applicant or beneficiary has the responsibility to:

1. Complete the PAAD eligibility application/renewal application form(s) legibly and accurately:

i. Answering all questions fully;

ii. Presenting all necessary evidentiary documents, including a copy of any third party health insurance cards and/or Medicare prescription benefits coverage cards;

iii. Reading the certification and authorization statement;

iv. Signing or marking the application or renewal application;

v. Obtaining the signature or mark of the spouse (if married) and the signature of the preparer (if applicable) on the application or renewal application.

2. Assist the Department in securing evidence that corroborates his statements when necessary.

3. Agree to a review by the Department or its agent, if randomly selected for review. PAAD eligibility may be terminated if the beneficiary refuses to cooperate with a quality control request.

4. Assign benefits to the State of New Jersey when prescription drug costs are covered in part by any other plan of assistance or insurance.

5. Reapply for eligibility, when requested to do so, on forms mailed by the Department, at least 45 days prior to his or her eligibility expiration date, if he or she wishes to renew PAAD eligibility.

6. If the application mailed by the PAAD Program is lost in the mail, misplaced or not received due to the applicant's change of address, it is the applicant's responsibility to contact the PAAD Program for a new application;

7. If the applicant does not wish the PAAD Program to act as his or her "authorized representative" for the purpose of coordinating Medicare and PAAD benefits, it is the applicant's responsibility to file a written "opt-out" letter with the program;

8. If requested, answer all questions and provide all information necessary to enroll the applicant in the Medicare Part D low income subsidy; and

9. If eligible, the applicant shall enroll in the Medicare Part D low income subsidy or permit the PAAD Program to enroll the applicant in the low income subsidy.

(d) The beneficiary has the responsibility to:

1. Notify PAAD whenever any one of the following occurs:

i. His or her marital status changes.

ii. He or she moves anywhere within the State of New Jersey, in which case, he or she shall submit proof of new address.

2. Return his or her eligibility card to PAAD whenever becoming ineligible due to one of the following:

i. He/she moves out of the State of New Jersey.

ii. He/she becomes eligible for Medicaid or any other plan of assistance or insurance that wholly covers pharmaceutical services.

iii. His/her or their annual income increases to an amount which exceeds the legal limit.

iv. He/she was determined eligible based on his/her disability and he/she stops receiving Social Security Disability benefits.

v. When requested by PAAD because required information to confirm eligibility was not submitted, or scheduled recovery payments are in arrears.

3. Repay the State of New Jersey, upon request, for the cost of benefits incorrectly paid on his or her behalf. Failure to fully repay the State for incorrectly paid benefits could cause the suspension of his or her PAAD benefits in the future, as well as possible withholding of all or some of his or her rebates or refunds which may be due him or her from the State of New Jersey.

Notes

N.J. Admin. Code § 10:167-5.6

As amended, R.1981 d.332, effective 9/10/1981.
See: 13 N.J.R. 432(a), 13 N.J.R. 580(c).
Amended by R.1985 d.259, effective 5/20/1985.
See: 17 N.J.R. 367(a), 17 N.J.R. 1318(a).
Amended by R.1991 d.563, effective 11/18/1991.
See: 23 N.J.R. 2623(a), 23 N.J.R. 3514(a).
Amended by R.1993 d.368, effective 7/19/1993.
See: 24 N.J.R. 4329(a), 25 N.J.R. 3216(a).
Amended by R.1995 d.10, effective 1/3/1995.
See: 26 N.J.R. 3142(a), 27 N.J.R. 242(a).
Amended by R.1998 d.176, effective 4/6/1998.
See: 29 N.J.R. 5280(a), 30 N.J.R. 1314(b).
Amended by R.2004 d.459, effective 12/20/2004.
See: 36 N.J.R. 3619(a), 36 N.J.R. 5682(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