Nursing Home’s Failure To Submit Timely Request for Clinical Screening Results In Denial Of Medicaid Application

Petitioner was admitted to Monmouth Medical Center. Thereafter, petitioner was discharged to Liberty Royal Rehabilitation and Health Care Center (Liberty Royal), a Medicaid certified nursing home. Less than one week later, he was transferred to Crystal Lake Nursing and Rehabilitation Center (Crystal Lake), another Medicaid certified nursing home. Petitioner remained at Crystal Lake until his discharge home. During his admission, petitioner filed for Medicaid benefits.

Nursing facilities are required to submit a request for Medicaid eligibility within 48 hours of a patient’s admission. The request is made by submission of a Notification from Long-Term Care Facility of the Admission or Termination of a Medicaid Patient (LTC-2) form. Submission of an LTC-2 form triggers Pre-Admission Screening (PAS) by a state agency, the Division of Aging Services, Office of Community Choice Options (OCCO). OCCO is responsible for establishing clinical eligibility for individuals seeking Medicaid services

Neither Liberty Royal nor Crystal Lake submitted an LTC-2 form on petitioner’s behalf within 48 hours of his admission to the facilities. Rather, the LTC-2 form was submitted nearly 3 months after petitioner was admitted to the facility and a week and a half after he was discharged.

Notwithstanding the untimeliness of the LTC-2 form, OCCO attempted to schedule the PAS required to establish Medicaid clinical eligibility. Upon being contacted, petitioner refused to meet with OCCO staff, stating he was not in need of any services. As a result, a PAS was not completed, leading to the denial of petitioner’s Medicaid application

Petitioner appealed the denial of his Medicaid application. The appeal was transferred to the Office of Administrative Law (OAL) as a contested case, and a fair hearing was conducted by an Administrative Law Judge (ALJ). The ALJ issued an initial decision affirming the denial of petitioner’s Medicaid application and dismissed the appeal. The Director of the state Medicaid agency in her final agency decision adopted the ALJ’s initial decision.

Petitioner appealed to the Superior Court of New Jersey, Appellate Division. Petitioner argued that because he completed all evaluations required by the Medicaid agency, the denial of his Medicaid application was arbitrary, capricious, and unreasonable.

The Appellate Division affirmed the denial of Medicaid benefits, holding:

In order to qualify for Medicaid benefits …,  petitioner was required to meet both financial and clinical eligibility requirements. Clinical eligibility is assessed through a PAS completed by professional staff designated by the [Medicaid agency] … The nursing home is responsible for notifying OCCO of petitioner’s admission to the facility and that a PAS must be completed. An LTC-2 was not submitted within forty-eight hours of petitioner’s admission. Instead, it was submitted thirteen days after his discharge home. Thereafter, petitioner refused to cooperate in completion of a PAS. Accordingly, petitioner never established clinical eligibility for the MLTSS waiver program. Therefore, petitioner’s Medicaid application was properly denied.

The case is annexed here – M.P. v. Division of Medical Assistance and Health Services

For additional information concerning Medicaid applications and appeals, visit:

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