N.J. Admin. Code § 11:24B-1.4

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

Section 11:24B-1.4 - CODS: suspension or revocation of a certification

(a) The Department may suspend or revoke the certification of a CODS upon a finding that:

1. The ODS is operating in contravention of its basic organizational documents;

2. The ODS is unable to fulfill its obligations to the carriers with which it has contracted;

3. The continued operation of the ODS would be detrimental to the carriers with which it has contracted to provide services, or hazardous to the health and welfare of the covered persons of the carriers with which the ODS has contracted to provide services;

4. The ODS is unable to maintain the standards applicable to it in this chapter;

5. The ODS has failed to comply with the applicable provisions of 26:2S-1 et seq., and rules promulgated pursuant thereto;

6. The ODS has failed to provide the services for which it was certified and has provided services in contravention of the contract or contracts filed with the Department, or the ODS has provided services pursuant to management agreements or provider agreements for which the ODS has not been approved;

7. The ODS has failed to comply with the Act, or with other applicable law not otherwise enumerated in (a)1 through 6 above; or

8. There are other grounds that the Department believes reasonably warrant suspension or revocation of the certification.

(b) When the Department orders a suspension or revocation of a certification, it shall do so in writing setting forth the grounds for the suspension or revocation, and setting forth a time for a hearing to be conducted in accordance with the Administrative Procedure Act, 52:14B-1 et seq., and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.

1. The suspension or revocation shall be effective no later than 10 days following the date of the written notice, but the effective date may be stayed until a final decision is issued following a hearing upon the written request of the ODS, unless the Department determines in writing that a stay of the suspension or revocation would be hazardous to the carrier(s) with which the ODS does business, or the covered persons of such carrier(s).

2. The ODS may waive its right to a hearing by providing affirmative notice of such a waiver to the agency issuing the notice of the suspension or revocation.

3. Unless the ODS waives its right to a hearing, the ODS shall submit with its request for the hearing, a written response to the notice of suspension or revocation either accepting or denying the findings set forth in the notice of suspension or revocation, and with respect to denials of the findings, specifying the factual and legal bases on which the ODS relies for denial of the findings.

(c) If an ODS' certification is revoked, the ODS shall submit to the Department within 15 days of the date of notice of the revocation, a plan for the winding-up of the ODS' affairs, and the ODS shall conduct no further business subject to the Act regardless of whether the revocation is stayed pending a hearing.

1. The ODS shall not engage in any business subject to the Act that is in addition to the business in which it was engaged on the date of the order of revocation, except that, if the Department stays the revocation pending the outcome of a hearing, the ODS may provide services to new covered persons of the carrier(s) with which it is contracted on the date of the order of revocation, unless the order specifies otherwise.

2. The ODS' plan to wind-up its business subject to the Act shall specify the means by which the ODS shall assure continuity of care for a carrier's covered persons, unless the order of revocation finds that the provision of continuity of care by the ODS would be hazardous to the carrier or the carrier's covered persons.

3. The ODS may request in writing that the Department approve the ODS to continue engaging in activities with carriers, which activities are not otherwise essential to the winding up of the ODS' business subject to the Act and the Department may grant such a request in its discretion.

4. The Department may permit or require an ODS to continue to engage in activities that are essential to the winding-up of an ODS' business subject to the Act, or additional activities, if the Department determines in writing that the performance of such activities are in the best interests of the covered persons of one or more carriers with which the ODS has a contract.

(d) The Department shall provide written notice to carriers contracted with an ODS of the suspension or revocation of the ODS' certification, and the proceedings therefor, except that the Department shall be obligated to notify only those carriers of which the Department has specific notice of a contract with the ODS.

1. The Department shall not be obligated to notify any other party doing business with the ODS of the suspension or revocation of the certification of the ODS.

N.J. Admin. Code § 11:24B-1.4