A New Jersey appeals court upheld the denial of Medicaid benefits to an applicant who failed to provide necessary verifications, rejecting the claim that the Medicaid agency’s failure to assist with the application prejudiced the applicant. P.B. v. Division of Medical Assistance and Health Services (N.J. Super. Ct., App. Div., No. A-5405-15T2, Dec. 8, 2017).

P.B.’s daughter filed an application for Medicaid on behalf of her mother in the Atlantic County Welfare Agency (CWA). Thereafter, the daughter did not attend a scheduled appointment.

Soon thereafter, the daughter submitted a second Medicaid application. The CWA advised the daughter that she needed to provide missing verifications so the application could be processed. It requested information about P.B.’s life insurance policy, bank statements and check images for bank accounts, and verification of P.B.’s lease or rental agreement.

The CWA made numerous written and oral follow-up requests for the required information, which was never provided. The CWA ultimately denied the application.

The daughter appealed. After conducting a hearing, the Administrative Law Judge (ALJ) reversed the CWA’s denial of the Medicaid application and remanded the matter to the CWA to work on getting the required information, ruling that the case must be decided on the merits unless P.B.’s daughter failed to cooperate without good cause.

The CWA appealed to the State Medicaid Agency. The CWA argued that the daughter failed to produce documentation despite numerous requests, and that, without this information it was impossible to ascertain Medicaid eligibility. P.B. argued the CWA mismanaged the initial application, and failed to provide her daughter with timely assistance, prejudicing P.B.

The state agency rejected the ALJ’s decision, upholding the decision to deny benefits. Although the Director of the State Medicaid Agency acknowledged that both the CWA and an applicant have responsibilities in the application process, the Director held that applicants have the sole responsibility to secure evidence. P.B.’s daughter appealed to court, again arguing that the Medicaid agency improperly failed to assist her with the application.

On appeal, the New Jersey Superior Court, Appellate Division, affirmed the State Medicaid Agency’s denial of Medicaid benefits. According to the court, P.B.’s daughter did not provide any evidence to show why she couldn’t comply with the state’s request for additional verifications, so the state properly denied P.B. Medicaid benefits.

The case is attached here – P.B. v. Division of Medical Assistance and Health Services

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