In this case, a New Jersey appeals court held that a disabled New Jersey resident eligible for Personal Care Assistance (PCA) services since 2009 was no longer eligible for PCA services under the Medicaid requirements. J.R. v. Division of Medical Assistance and Health Services, Docket No. A-0648-14T3 (App. Div.,  April 18, 2016

J.R. was diagnosed with Tourette’s syndrome and several other medical conditions. He lived with his mother and began receiving PCA services, paid for by Medicaid, in May 2009 to help him perform activities of daily living (ADLs), such as grooming, bathing, eating, dressing, and the like.

In 2013, a registered nurse reassessed J.R.’s continued need for PCA services. The nurse employed the PCA Beneficiary Assessment Tool (PCA Tool), required by NJ regulations, and concluded that J.R. no longer demonstrated a need for continued PCA services. As a result, J.R.’s PCA services were terminated.  J.R. requested a hearing, and the matter was transferred to the Office of Administrative Law for a hearing before an administrative law judge (ALJ).

Prior to the hearing, the state undertook another reassessment of J.R.’s eligibility. A new registered nursed was assigned. The nurse met with J.R. and his mother in their home, conducted another clinical evaluation of him, and again employed the PCA Tool. Like the first nurse, the new nurse also concluded that J.R. was ineligible for continued PCA services.

The hearing was held after the second assessment was concluded. At the hearing, the ALJ heard from several witnesses. Thereafter, the ALJ concluded that J.R. no longer needed PCA services. J.R. again appealed.

The Superior Court of New Jersey, Appellate Division, heard the new appeal.  In the Appellate Division, J.R. argued that the ALJ’s decision was arbitrary, capricious, and not supported by the record. Further, he argued that the ALJ engaged in improper rule-making in determining he was ineligible for PCA benefits because of the intermittent nature of his ailment. He also contended that the ALJ reached his conclusion by relying upon the PCA Tool, which he argued is flawed.

The appeals court upheld the ALJ’s decision. The court ruled that the ALJ’s decision was supported by evidence on the record. Specifically, the court held that the findings and conclusions of the first reassessment nurse were independently verified by the second reassessment nurse. Each employed the PCA Tool, in conjunction with a face-to-face clinical appraisal, to conclude that J.R. was capable of living independently with his mother, despite being subject to an occasional seizure, which would interfere with his ADLs. Therefore, the court, like the ALJ, ruled J.R. to be ineligible for continued PCA services.

The case is annexed here – J.R. v. Division of Medical Assistance and Health Services

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