Medicaid’s Filing Deadline For An Appeal Can Be Extended Based On “Extraordinary And Extenuating Circumstances”

Medicaid denial based upon untimely appeal reversedMedicaid denial based upon untimely appeal reversed

An appeal of a claim for Medicaid benefits that was filed late may be considered when the applicant shows that the filing deadline should be extended due to “extraordinary and extenuating circumstances.” Reuter v. Division of Medical Assistance and Health Services, Docket No. A-0514-13T2 (App. Div., October 17, 2014)

Plaintiff, Greta Reuter, a nursing home resident, applied for Medicaid with the Burlington County Board of Social Services. On March 28, 2013, the Medicaid agency notified the applicant by letter that it approved Medicaid benefits retroactively for the period of June 1, 2012 through September 30, 2012 and also for the month of May 2012, but denied future benefits because of the alleged failure to provide additional information requested by the agency. The letter also notified the applicant that she had twenty days to request a Fair Hearing to challenge the decision.

The Medicaid agency had no proof that the March 28, 2013 letter was either mailed by the agency or received by the plaintiff at her nursing home. In fact, plaintiff claimed that she did not learn of the letter and its contents, including the notice advising her of appeal rights, until months later on July 25, 2013 when the letter was faxed to her counsel by the agency at his request. According to plaintiff, her attorney initiated contact with the agency because neither he nor plaintiff had heard anything from the Medicaid agency for some time.

On August 2, 2013, eight days after he received a faxed copy of the agency’s letter, plaintiff’s attorney faxed and mailed a letter to the Medicaid agency requesting a Fair Hearing. In that letter, counsel represented that his office had not been notified before July 25, 2013 of the agency’s termination of future benefits. He also represented that plaintiff’s nursing home likewise had not received notice.

Medicaid denied the plaintiff’s request for a Fair Hearing, claiming that the request was untimely, having been made 127 days after the date of the March 28 letter. The agency would not extend the appeals deadline. Plaintiff appealed, contending that the agency’s denial of her Fair Hearing request, and its refusal to extend the twenty-day deadline, was arbitrary and capricious.

The appeals court reversed, permitting plaintiff to appeal the denial of Medicaid benefits. The court held that the Medicaid agency acted arbitrarily and capriciously by summarily rejecting appellant’s contention that she did not receive the March 28, 2013 letter from the agency, despite the absence of any proof that the letter was either mailed by the agency or received by the plaintiff.

The court also offered what it characterized as a “pragmatic observation:”

Given the totality of circumstances here, it would strain common sense for [plaintiff], her family members, and her attorney to have disregarded the letter when it supposedly arrived and have waited 127 days to pursue a fair hearing. [Plaintiff] had submitted an application for important financial benefits relating to her ongoing care at a nursing home. That application was reasonably believed to be pending until her attorney took the initiative to contact the agency and ascertain the status of the matter in July 2013. Once informed of that status, the attorney responded within eight days with a fair hearing request. … The course of events that transpired is consistent with the credibility of [plaintiff’s] assertion that she never got the letter in March 2013 or within the twenty-day period of its issuance.

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

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