Medicaid Denial Based On Nursing Home’s Failure To Request Clinical Screening Of Applicant Affirmed

E.S. was admitted to Brookdale Assisted Living Facility (Brookdale) in April 2015. E.S. was paying for care privately from her own savings at that time. Realizing in December 2016 that E.S.’s financial resources would cover the cost of care for only a few more months, B.S., E.S.’s daughter and authorized representative, asked Brookdale to start the Medicaid application process. The application was filed, but was denied due to the lack of a fully executed PA-4 form, a physician’s certification. A second application was filed in May 2017 correcting that deficiency.

Upon reviewing the application, however, the Camden County Board of Social Services (the Board), saw that a Pre-Admission Screening (PAS) evaluation, which determines a patient’s clinical eligibility under the Medicaid program, had not been conducted. Under Medicaid regulations in New Jersey, the PAS is performed by the Division of Aging Services, Office of Community Choice Options (OCCO). The Board forwarded the application to OCCO in June, and later that month OCCO performed a PAS on E.S. The Board determined on July 24, that E.S. was clinically eligible for the Medicaid program effective July 1, 2017.

E.S. requested a fair hearing before an Administrative Law Judge (ALJ) claiming she should have a May 1 effective date for her Medicaid benefits. However, following a hearing, the ALJ issued an initial decision affirming the Board’s decision. The ALJ reasoned there was no dispute that a PAS was not completed until July 2017, and since “[t]he OCCO does not back date [its PAS] approvals …,” the Medicaid benefits for E.S.’s assisted living care should remain effective on July 1, 2017.

After reviewing the record, the Division issued a final agency decision adopting “the recommended decision of the [ALJ] in its entirety and incorporate[d] the same herein by reference.” E.S. filed an appeal to the Superior Court of New Jersey, Appellate Division.

In considering E.S.’s appeal, the appeals court recognized that, in order to qualify for Medicaid benefits, E.S. was required to meet both Medicaid financial and clinical eligibility requirements for nursing care services. Clinical eligibility is determined through the PAS procedure. PAS is “based on a comprehensive needs assessment that demonstrates that the beneficiary requires, at a minimum, the basic [nursing facility] services. . .“

The appeals court then affirmed the Board’s decision, holding as follows:

[S]tate law clearly requires that [E.S.] be determined to be clinically eligible based upon a PAS. As for the effective date of E.S.’s Medicaid benefits, there is no factual or legal basis for her claim that the effective date should be May 1, 2017. The fact that a PAS was not done until July 2017 was not the fault of the Board nor the Division. Brookdale was the nursing facility providing services to E.S. Under the law, it was its responsibility – not the Board’s –to request a PAS for E.S. to enable her to receive Medicaid benefits. We discern nothing arbitrary, capricious, or unreasonable concerning the Division’s decision to make E.S.’s benefits effective July 1, 2017 … .

The case is attached here – E.S. v. Division of Medical Assistance and Health Services

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