Agency’s Significant Delay in Processing Medicaid Application in Blatant Violation of Regulations Results in No Sanctions

Agency’s Delay in Processing Medicaid Application Results in No SanctionsAgency’s Delay in Processing Medicaid Application Results in No Sanctions

In A.H. v. Division of Medical Assistance and Health Services, 2014 N.J. Agen. LEXIS 91 (OAL Dkt. No. HMA 00531-13, Jan. 27, 2014), fifteen months elapsed between the assisted living facility resident’s application for Medicaid benefits under the “Global Options” program and the formal denial of the claim. During this time, in which there were various delays on the part of Medicaid in processing the application, a Medicaid caseworker also miscalculated the applicant’s income. As a result, in September 2012, Medicaid mistakenly found that the applicant was eligible for Global Options. Three and a half months later, Medicaid realized its mistake and formally denied the application. In the interim, according to the applicant’s son, no one informed him that the application might be denied, or that his mother might be eligible for another Medicaid program. A.H. was soon transferred to a nursing home and approved for the Medically Needy program. However, there remained an unpaid balance to the assisted living facility.

The Medicaid applicant appealed Medicaid’s decision to an Administrative Law Judge (“ALJ”). In the initial decision, the ALJ noted that retroactive eligibility is not available to Medicaid waiver program beneficiaries; however, Medicaid regulations require that applications be determined within 45 days, unless Medicaid can demonstrate “exceptional” circumstances. Notwithstanding this requirement, the ALJ noted that “the consequences of a County Welfare Agency’s failure to comply with these regulatory requirements are unclear,” and that, on further appeal, the Medicaid Director rejects and modifies initial decisions that conclude such delay entitles the applicant to benefits.

The ALJ quoted language from M.T. v. Division of Medical Assistance and Health Services, No. A-1777-11 (App. Div. Mar. 20, 2013), which held that “there must be some consequence to non-compliance, and that the regulation is not merely aspiration.” However, the A.H. ALJ declined to order retroactivity, because retroactivity is prohibited under Global Options and because the applicant was never eligible for Global Options.

It is my understanding that the Director affirmed the ALJ in an unreported decision. A copy of the Initial Decision is attached here – A.H. v. Division of Medical Assistance and Health Services

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