N.J. Admin. Code § 10:78-10.1

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

Section 10:78-10.1 - Termination of eligibility for good cause for fraud and abuse

(a) Subject to the limitations contained in 42 U.S.C. § 1320a- 7b(a), "Criminal Penalties for Acts involving Federal Health Care Programs," any violation of (b) below shall result in the issuance of a Notice of Proposed Termination of the processing of the applicant's application, or of the beneficiary's eligibility for NJ FamilyCare. An individual receiving a Notice of Proposed Termination may request a grievance review.

(b) Subject to the limitations contained in 42 U.S.C. § 1320a- 7b(a), cause for termination exists when a NJ FamilyCare applicant or beneficiary:

1. Knowingly or intentionally makes or causes to be made false statements or misrepresentations of material fact in any application or reapplication for benefits under NJ FamilyCare;

2. Knowingly or intentionally makes or causes to be made false statements, misrepresentations of material fact, or alterations on any NJ FamilyCare claim, eligibility card, or other document issued by or on behalf of the Division;

3. Intentionally misuses or abuses NJ FamilyCare benefits;

4. Knowingly or intentionally converts all or part of NJ FamilyCare benefits to a use other than the individual's own legitimate use and benefit;

5. Gives, loans, or sells 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. Engages in forgery or attempted forgery involving eligible services and/or claims for such services;

7. Engages in a course of conduct or performs an act deemed improper or abusive of the NJ FamilyCare program following notification that this conduct should cease; or

8. Fails to cooperate in a NJ FamilyCare investigation.

(c) Subject to the limitations contained in 42 U.S.C. § 1320a- 7b(a), the existence of a cause for termination described in (b) above may be established by:

1. A judgment of conviction for a crime, disorderly persons offense, or petty disorderly persons offense;

2. A judgment or order of either a court of competent jurisdiction or an administrative agency; or

3. A preponderance of the evidence.

N.J. Admin. Code § 10:78-10.1