N.J. Admin. Code § 10:79-7.1 - Termination of eligibility for good cause for fraud and abuse

Current through Register Vol. 54, No. 7, April 4, 2022

(a) Any violation of (b) below by an applicant, beneficiary, caretaker adult or authorized agent may result in the termination of the applicant's or beneficiary's eligibility from NJ FamilyCare-Children's Program-Plan B, C and D. An individual receiving a Notice of Proposed Termination issued by the Director of the Division may request, within 20 days of the date of the Notice, an administrative law hearing before the Office of Administrative Law. The Notice shall be dated at least 20 days prior to the end of the month in which the termination is effective. Failure to request a hearing within this time limit shall result in automatic termination of benefits. Until such time as a final agency decision is issued by the Director as a result of such a hearing which terminates an individual from NJ FamilyCare-Children's Program-Plan B, C and D, the individual shall remain eligible for such benefits, unless the Director determines and states in the Notice of Proposed Termination that temporary suspension of benefits prior to a hearing is necessary to protect the integrity of the NJ FamilyCare-Children's Program-Plan B, C and D program and/or the health, safety or welfare of other NJ FamilyCare-Children's Program-Plan B, C and D beneficiaries.
(b) The following grounds shall constitute good cause for termination:
1. Knowingly or intentionally making or causing to be made false statements or misrepresentations of material fact in any application or reapplication for benefits under NJ FamilyCare-Children's Program-Plan B, C or D;
2. Knowingly or intentionally making or causing to be made false statements, misrepresentation of material fact, or alterations on any NJ FamilyCare-Children's Program-Plan B, C and D program claim form, eligibility card, or other document issued by or on behalf of the Division;
3. Intentionally misusing or abusing NJ FamilyCare-Children's Program-Plan B, C or D program benefits;
4. Knowingly or intentionally converting all or part of NJ FamilyCare-Children's Program-Plan B, C or D program benefits to a use other than the individual's own legitimate use and benefit;
5. Giving, loaning, or selling an eligibility card to anyone for use by an individual or individuals other than the eligible person or persons for whom the card was issued;
6. Forgery or attempted forgery involving eligible services and/or claim forms for such services;
7. Engaging in a course of conduct or performing an act deemed improper or abusive of the NJ FamilyCare-Children's Program following notification that this conduct should cease; or
8. Failure to cooperate in a NJ FamilyCare-Children's Program investigation.
(c) The existence of a cause for termination described in (b) above may be established by a judgment of conviction for a crime, disorderly persons offense, or petty disorderly persons offense; a judgment or order of either a court of competent jurisdiction or an administrative agency; or by a preponderance of the evidence.

Notes

N.J. Admin. Code § 10:79-7.1
Adopted concurrent proposal, R.1998 d.487, effective 8/28/1998.
See: 30 New Jersey Register 1060(a), 30 New Jersey Register 3519(a).
Readopted the provisions of R.1998 d.154 without change.
Amended by R.1999 d.211, effective 7/6/1999 (operative August 1, 1999).
See: 31 New Jersey Register 998(a), 31 New Jersey Register 1806(a), 31 New Jersey Register 2879(b).
In (a) and (b), inserted references to Plan D throughout.
Amended by R.2004 d.42, effective 1/20/2004.
See: 35 New Jersey Register 3802(a), 36 New Jersey Register 572(b).

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