A2443

An Act concerning Medicaid and supplementing P.L.1968, c.413 (C.30:4D-1 et seq.).

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. a. In the event that an individual who enrolled in the Medicaid or NJ FamilyCare program is determined to have been ineligible for enrollment, the amount that may be recovered from the individual or the individual’s estate shall not exceed the actual cost to the program of the individual’s enrollment in the program during the period of improper enrollment, or $500, whichever is less, provided that:

(1) the period during which the individual was improperly enrolled was less than 12 months;

(2) the individual’s improper enrollment is directly attributable to administrative error on the part of the Division of Medical Assistance and Health Services in the Department of Human Services, an agent of the division, or a county welfare agency; and

(3) the individual did not receive any medical assistance or other services through the Medicaid or NJ FamilyCare programs during the period of improper enrollment.

b. Subsection a. of this section shall not apply to any situation involving any misleading or fraudulent conduct on the part of an individual enrolled in the Medicaid or NJ FamilyCare program or the individual’s authorized representative, including, but not limited to, misrepresenting the individual’s income or failing to notify the division of a change in circumstances pertinent to the individual’s eligibility for enrollment.

c. Nothing in this section shall be construed to limit the ability of the division to seek recovery from an enrollee or the enrollee’s estate or any other person from whom recovery may be sought in any situation other than that expressly set forth in subsection a. of this section, including, but not limited to, situations involving fraud, third party liability, or any period of proper and appropriate enrollment in the Medicaid or NJ FamilyCare programs.

2. The Commissioner of Human Services shall apply for such State plan waivers or amendments as may be necessary to implement the provisions of this act and to secure full federal financial participation for State Medicaid expenditures under the federal Medicaid program.

3. This act shall take effect immediately.

STATEMENT

This bill limits the amount that may be recovered from certain individuals who were improperly enrolled in the Medicaid or NJ FamilyCare program due to an administrative error.

Specifically, if the individual was ineligible for benefits and the individual was improperly enrolled for less than 12 months, did not receive any medical assistance or other services during the period of improper enrollment, and the improper enrollment is directly attributable to an administrative error on the part of the Division of Medical Assistance and Health Services in the Department of Human Services, an agent of the division, or a county welfare agency, the amount that the program may recover from the individual or the individual’s estate will be limited to the actual cost to the program of the individual’s enrollment during the period of improper enrollment, or $500, whichever is less.

The provisions of the bill will not apply in any situation involving misleading or fraudulent conduct on the part of an individual or the individual’s authorized representative, and nothing in the bill is to be construed to prevent recovery from any other person in any other situation other than that expressly set forth in the bill, including, but not limited to, situations involving fraud, third party liability, or proper and appropriate enrollment in Medicaid or NJ FamilyCare.

It is the sponsor’s belief that it is appropriate to limit the amount that may be recovered from individuals who are improperly enrolled in Medicaid or NJ FamilyCare because of an administrative error, and who do not use any benefits while enrolled, because the cost to the program of the improper enrollment will generally be limited to administrative expenses.