Medicaid denied where complete verification of assets not provided J.H.,
Petitioner-Appellant,
v.
DIVISION OF MEDICAL ASSISTANCE
AND HEALTH SERVICES,
Respondent-Respondent,
and
OCEAN COUNTY BOARD OF SOCIAL SERVICES,
Respondent.
Submitted February 6, 2018 – Decided February 21, 2018
Before Judges Carroll and Leone.
On appeal from the Department of Human
Services, Division of Medical Assistance and
Health Services.
SB2 Inc., attorneys for appellant (Ada Sachter
Gallicchio, on the briefs).
Gurbir S. Grewal, Attorney General, attorney
for respondent (Melissa H. Raksa, Assistant
Attorney General, of counsel; Lauren S. Kirk,
Deputy Attorney General, on the brief).NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION
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SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
DOCKET NO. A-2147-16T3
PER CURIAM
J.H. appeals the November 23, 2016 final agency decision of
the Division of Medical Assistance and Health Services (DMAHS)
that denied her application for Medicaid benefits. We affirm.
J.H. submitted an application for Medicaid benefits to the
Ocean County Board of Social Services (OCBSS) on February 22,
2016. That same day, OCBSS provided a letter to J.H. requesting
documentation and verification required to determine her
eligibility.
On February 26, 2016, OCBSS sent J.H. a notice requesting the
following information: (1) verification of a $159.83 payment to
Allstate and the policy's cash surrender value if it was a life
insurance policy; (2) current statements for a Wells Fargo checking
account, and verification for twenty-one designated payments and
cash withdrawals totaling more than $14,000 during the period
between February 8, 2012, and November 30, 2015; (3) the listing
agreement for J.H.'s home; (4) information regarding the purpose
of a separate $334.75 payment; and (5) "[a]ny and all pertinent
verifications of all resources solely or jointly owned (bank
accounts, C.D.'s, stocks, bonds, money markets, 401K's, IRA's,
annuities, trusts, cash surrender value of life insurance
policies, etc.) opened or closed in the last [five] years prior
to application in addition to the accounts listed above." The
2 A-2147-16T3
notice advised J.H. of the name and phone number of the OCBSS
representative J.H. could call "if [she] ha[d] any questions
regarding this matter." Finally, the notice instructed J.H. her
application could be denied if she failed to furnish the requested
information by March 7, 2016.
On March 7, 2016, OCBSS sent J.H. another notice advising
that her application could be denied if she failed to supply the
information by March 21, 2016. On March 21, 2016, OCBSS sent J.H.
a "final notice," again requesting information concerning bank
accounts and insurance policies. J.H. was instructed to supply
the information by April 4, 2016, or OCBSS "may take action to
deny" her application. As with the prior notices, OCBSS provided
J.H. with the name and phone number of its representative to call
if she had any questions. On April 13, 2016, J.H.'s application
for Medicaid was denied for non-compliance with the February 26,
March 7, and March 21, 2016 notices.
At J.H.'s request, a hearing was conducted concerning the
denial of her application. On September 30, 2016, an
Administrative Law Judge (ALJ) issued an Initial Decision
affirming the denial of Medicaid benefits to J.H. In his written
opinion, the ALJ determined:
The issue in this case is whether [OCBSS]
appropriately denied [J.H.'s] application
when she did not provide the requested
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information by April 4, 2016. 42 C.F.R. §
435.912(c)(3) and N.J.A.C. 10:71-2.3(a)
provide that the agency has forty-five days
to render a decision on eligibility for an
applicant who is not applying on the basis of
disability. In the present case, [OCBSS]
advised [J.H.] a number of documents and
explanations were requested. There is no
dispute that those documents were not received
on time and one [was received] after the
application had been denied. In addition,
some of the verifications were not provided
at all because there were no records produced
regarding the commingled bank account.
The ALJ also rejected J.H.'s argument that OCBSS should have
assisted her in securing the requested information. The ALJ found
J.H. never requested assistance and that at all times OCBSS dealt
only with J.H.'s authorized representative at Future Care
Consultants.
On administrative appeal to the DMAHS, the Director reviewed
the record, including the ALJ's Initial Decision, and adopted the
findings and conclusions of the ALJ in their entirety. The
Director concluded "[t]he credible evidence in the record
demonstrates that [J.H.] failed to provide the needed information
prior to the April 13, 2016 denial of benefits. Without this
information, OCBSS was unable to complete its eligibility
determination and the denial was appropriate."
On appeal, J.H. contends DMAHS's final decision was arbitrary
and capricious. Specifically, she argues: (1) the ALJ was biased
4 A-2147-16T3
against her; (2) the ALJ failed to provide an analysis as part of
his decision; (3) OCBSS violated her due process rights by failing
to provide adequate notice of the denial; and (4) OCBSS failed to
offer her the necessary assistance with her Medicaid application.
We review an agency's decision for the limited purpose of
determining whether its action was arbitrary, capricious or
unreasonable. "An administrative agency's decision will be upheld
'unless there is a clear showing that it is arbitrary, capricious,
or unreasonable, or that it lacks fair support in the record.'"
R.S. v. Div of Med. Assistance and Health Servs.,
434 N.J. Super.
250, 261 (App. Div. 2014) (quoting Russo v. Bd. of Trs., Police &
Firemen's Ret. Sys.,
206 N.J. 14, 25 (2011)). "The burden of
demonstrating that the agency's action was arbitrary, capricious
or unreasonable rests upon the [party] challenging the
administrative action." E.S. v. Div. of Med. Assistance & Health
Servs.,
412 N.J. Super. 340, 349 (App. Div. 2010) (alteration in
original) (quoting In re Arenas,
385 N.J. Super. 440, 443-44 (App.
Div. 2006)).
"Medicaid is a federally-created, state-implemented program
that provides 'medical assistance to the poor at the expense of
the public.'" Matter of Estate of Brown,
448 N.J. Super. 252, 256
(App Div.) (quoting Estate of DeMartino v. Div. of Med. Assistance
& Health Servs.,
373 N.J. Super. 210, 217 (App. Div. 2004); 42
5 A-2147-16T3
U.S.C.A. § 1396-1), certif. denied,
230 N.J. 393 (2017). To
receive federal funding, the State must comply with all the federal
statutes and regulations. Harris v. McRae,
448 U.S. 297 (1980).
In New Jersey, the Medicaid program is administered by DMAHS
pursuant to the New Jersey Medical Assistance and Health Services
Act,
N.J.S.A. 30:4D-1 to -19.5. "In order to be financially
eligible, the applicant must meet both income and resource
standards." Brown,
448 N.J. Super. at 257 (citing N.J.A.C. 10:71-
3.15). The county welfare boards evaluate eligibility. Through
those county agencies, DMAHS serves as a "gatekeeper to prevent
individuals from using Medicaid to avoid payment of their fair
share for long-term care." W.T. v. Div. of Med. Assistance &
Health Servs.,
391 N.J. Super. 25, 37 (App. Div. 2007) (citing
N.J.S.A. 30:4D-1 to -19.1).
DMAHS's regulations establish "policy and procedures for the
application process." N.J.A.C. 10:71-2.2(b). The county welfare
boards exercise "direct responsibility in the application process
to . . . [r]eceive applications." N.J.A.C. 10:71-2.2(c). They
also "[a]ssure the prompt and accurate submission of eligibility
data." N.J.A.C. 10:71-2.2(c)(5). The regulations establish time
frames to process an application, with the "date of effective
disposition" being the "effective date of the application" where
the application has been approved. N.J.A.C. 10:71-2.3(b)(1).
6 A-2147-16T3
Under both federal and New Jersey law, except in unusual or
exceptional circumstances, Medicaid eligibility determinations
must be made within forty-five days. 42 C.F.R. §
435.912(c)(3)(ii); N.J.A.C. 10:71-2.3(a). Examples of exceptional
cases where the forty-five day period can be enlarged include:
1. Circumstances wholly within the applicant's
control; [or]
2. A determination to afford the applicant,
whose proof of eligibility has been
inconclusive, a further opportunity to develop
additional evidence of eligibility before
final action on his or her application[.]
[N.J.A.C. 10:71-2.3(c)(1)-(2).]
Here, DMAHS's final agency decision was not arbitrary,
capricious or unreasonable. J.H. does not dispute that: her
application for Medicaid was filed on February 22, 2016; she was
given four opportunities to provide the information necessary to
determine her eligibility for benefits; she did not timely submit
all the required information; and she never requested additional
time. When the verifying information was not timely provided,
DMAHS properly denied the application. DMAHS was correct to deny
an application that did not have the information necessary to
verify eligibility because Medicaid is intended to be a resource
of last resort and is reserved for those who have a financial or
7 A-2147-16T3
medical need for assistance. See N.E. v. Div. of Med. Assistance
& Health Servs.,
399 N.J. Super. 566, 572 (App. Div. 2008).
J.H. has failed to demonstrate any unusual or exceptional
circumstances that would warrant a continuation of her eligibility
determination beyond the normal forty-five day deadline.
Moreover, contrary to J.H.'s argument, the notice of denial was
adequate because it stated it was for non-compliance, it identified
the contact letters to which plaintiff failed to respond, and the
letters detailed the information requested. While J.H. complains
OCBSS failed to assist her in obtaining the information necessary
to complete her Medicaid application, the record is devoid of any
indication that either J.H. or her authorized representative ever
sought such assistance.
After carefully reviewing the record and the applicable legal
principles, we conclude that J.H.'s further arguments are without
sufficient merit to warrant discussion in a written opinion, Rule
2:11-3(e)(1)(E), and that the agency's decision is supported by
sufficient credible evidence in the record. R. 2:11-3(e)(1)(D).
Affirmed.
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