T.M., a 23 year old disabled woman, has spinal muscular atrophy, is paralyzed, and is dependent on a ventilator to breathe. She resides with her grandmother who is also her primary caregiver. For many years, T.M. had been receiving private duty nursing (PDN) and personal care assistance (PCA) services through Medicaid under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. Under that program, children under the age of 21 were eligible to receive any medically necessary service. Once T.M. turned 21 and aged out of the EPSDT program, she began receiving Medicaid services through Managed Long Term Services and Supports (MLTSS), administered by United Healthcare Community Plan (United), a Managed Care Organization (MCO).

Under MLTSS, T.M. received 16 hours of daily PDN services, totaling 112 hours per week, and 4 hours of PCA services six days a week, totaling twenty-four hours per week. Following a reassessment of T.M., however, United advised T.M. that her PCA services were being “terminat[ed]” because T.M.’s “private duty nurse [was taking] care of both [her] skilled needs and [her] personal care needs.”

T.M. promptly filed a stage one appeal, which was denied. United advised T.M. that 24 hours per week of PCA services were “not medically needed.” T.M. then filed a stage two appeal, which was also denied. T.M. requested a fair hearing to contest the termination, and the matter was transmitted to the Office of Administrative Law (OAL) for a hearing before an administrative law judge (ALJ). After both parties moved for summary decision, the ALJ granted T.M.’s motion, denied United’s cross-motion, and determined that United’s “decision to terminate [T.M.’s] PCA hours was not appropriate.”

United filed exceptions to the ALJ’s initial decision, and the Director of the state Medicaid office issued a final agency decision reversing the ALJ’s decision and reinstating United’s termination of T.M.’s PCA services. The Director stated that the dispute “focuses on whether [T.M.] may also receive [twenty-four] hours of weekly PCA services in addition to the [sixteen] hours of [daily] PDN she receives.” The Director determined that while “the ALJ [was] correct that there [was] no explicit prohibition in the regulations disallowing the provision of PCA services,” in this case, “regulatory and contractual requirements . . . preclude[d] T.M. from receiving more than [sixteen] hours per day of hands-on care and require[d] the primary caregiver to perform [eight] hours of daily hands-on care.”

T.M. filed an appeal to the Superior Court of New Jersey, Appellate Division, claiming that the elimination of PCA services was arbitrary, capricious, and unreasonable. After reviewing the record, the appeals court affirmed the decision made by the state Director of Medicaid. The court held as follows:

MLTSS is the Medicaid program at issue here. As a recipient of services under MLTSS, T.M. was subject to the regulatory proscriptions . . . which limited PDN services to a maximum of 16 hours daily, and required the primary caregiver to provide a minimum of 8 hours of care daily. Combined, the regulation ensures a total of 24 hours of daily care. PDN services include assistance with ADL, and the primary caregiver provides hands-on care. Therefore, inasmuch as the services provided by T.M.’s PCA were already being provided by her PDN and her grandmother, and services cannot logically exceed twenty-four hours per day, as the Director determined, the PCA services were duplicative and medically unnecessary. We reach this conclusion notwithstanding the fact that PCA services are not expressly prohibited by the Medicaid regulations. As the agency responsible for protecting the interests of the New Jersey Medicaid program and its beneficiaries, we are satisfied that the Director’s decision that Medicaid funds should not be used to subsidize duplicative services is hardly arbitrary, capricious, unreasonable, or lacking fair support in this record.

The case is attached here – T.M. v. Division of Medical Assistance and Health Services

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