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
See: 13 N.J.R. 432(a), 13 N.J.R. 580(c).
Amended by R.1985 d.259, effective
See: 17 N.J.R. 367(a), 17 N.J.R. 1318(a).
Amended by R.1991 d.563, effective
See: 23 N.J.R. 2623(a), 23 N.J.R. 3514(a).
Amended by R.1993 d.368, effective
See: 24 N.J.R. 4329(a), 25 N.J.R. 3216(a).
Amended by R.1995 d.10, effective
See: 26 N.J.R. 3142(a), 27 N.J.R. 242(a).
Amended by R.1998 d.176, effective
See: 29 N.J.R. 5280(a), 30 N.J.R. 1314(b).
Amended by R.2004 d.459, effective
See: 36 N.J.R. 3619(a), 36 N.J.R. 5682(b).
Amended by R.2009 d.16, effective
See: 40 N.J.R. 4479(a), 41 N.J.R. 221(a).
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