G.M., a 73 year old stroke victim, was diagnosed with Alzheimer’s disease, vascular dementia, schizoaffective and bipolar disorders. After G.M. filed a Medicaid application, the Atlantic County Board of Social Services (Board) notified G.M. that his application was denied because he did not provide necessary information.

Several months later, G.M.’s designated authorized representative (DAR) submitted a second application for Medicaid benefits on behalf of G.M. The Board requested information from UBS confirming there was no balance remaining in G.M.’s pension plan, and the Board sought copies of G.M.’s Wells Fargo bank statements for a bank account G.M. disclosed on his application.

After it did not receive the requested information, the Board extended the deadline for submitted the requested information several times. G.M.’s counsel wrote a letter requesting that the Board stay the processing of his Medicaid application pending the appointment of a guardian for G.M.

The letter also advised the Board that G.M.’s sister and power-of-attorney (POA) lost several documents and was unable to provide the authorizations requested by Wells Fargo and UBS. After not receiving the requested information by the extended deadline, the Board denied G.M.’s second application.

Petitioner filed an administrative appeal of the denial of Medicaid benefits, requesting a fair hearing.  While the hearing was pending, the DAR provided a UBS statement and a statement from a Wells Fargo account which was not previously disclosed.

An Administrative Law Judge (ALJ) conducted a hearing. During the hearing, the Board provided explanations for its denial of G.M.’s Medicaid application. No testimony was offered by the DAR. The DAR relied upon her pre-hearing summary detailing the attempts made to obtain the information from Wells Fargo, UBS and G.M.’s sister, who was ill and could not locate the relevant documents.

The ALJ issued an initial decision affirming the denial of petitioner’s Medicaid eligibility. The Director of the state Medicaid agency adopted the ALJ’s findings, stating the Board granted “numerous extensions of time to provide the information that could not be obtained through any verification system[,]” and the claim that G.M.’s sister was incapacitated “is not supported by the record.”

G.M. again appealed, this time to the Superior Court of New Jersey, Appellate Division. The DAR argued that, because both G.M. and his sister suffered from compromised medical conditions, the Board had a duty to assist G.M. by contacting the financial institutions to verify his resources. Because the Board failed to contact his financial institutions, the determination of his Medicaid ineligibility was arbitrary, capricious, and unreasonable.

The Court recognized that “[a]ppellate review of the Division’s final agency action is limited… “[A]n appellate court ordinarily should not disturb an administrative agency’s determinations or findings unless there is a clear showing that (1) the agency did not follow the law; (2) the decision was arbitrary, capricious, or unreasonable; or (3) the decision was not supported by substantial evidence.” [citations omitted]

The appeals court agreed with the Division’s conclusion that nothing in the record showed the Board failed to assist G.M. Moreover, the Board “granted numerous extensions of time” to G.M. to provide the requested information. G.M.’s documents were mailed to his sister as his POA and no evidence was produced to prove she was incapacitated. As a result, the Court concluded the Director’s findings are supported by sufficient credible evidence in the record, and that the final agency decision was not arbitrary, capricious, or unreasonable.

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

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