E.H. submitted a Medicaid application to the Hudson County Division of Welfare (HCDW) and designated Future Care Consultants (FCC) as her designated authorized representative (DAR). Shortly thereafter, the HCDW denied the application because E.H. failed to provide her husband’s bank records for the five-year look-back period.

FCC appealed the denial, submitting a request for a hearing. In response, the agency requested a copy of HCDW’s denial notice. The letter also notified FCC that the case would be closed if it did not receive the requested information within 30 days. FCC then sent a copy of the HCDW’s denial letter to the agency.

Soon thereafter, E.H. passed away. Several months later, FCC was advised that, because E.H. had died, the fair hearing request would not be granted until the executor of E.H.’s estate signed a DAR form. The agency did not confirm this decision in writing.

In response, FCC notified the Medicaid agency that there was no federal and state law requiring the executor of E.H.’s estate to sign an additional DAR form to perfect the appeal on her behalf. Accordingly, FCC requested that the appeal be transmitted to the Office of Administrative Law (OAL) for a hearing. As the agency did not respond, FCC appealed to the Superior Court of New Jersey, Appellate Division.

In the appeals court, the Medicaid agency argued that the appeal was untimely because FCC did not provide a copy of HCDW’s denial notice until 38 days after the denial was issued, and any appeal from a Medicaid denial must be filed within 20 days after gthe denial is issued under the rules. The Court held the agency’s position to be without merit, ruling that federal and state regulations providing for a fair hearing do not require applicants to include a copy of the agency’s denial notice in their request.

The Court also ruled that the agency’s failure to provide FCC with a written decision denying E.H.’s application for failure to provide an additional DAR form signed by E.H.’s executor or notice of its right to judicial review violated federal and state Medicaid regulations. Accordingly, the Court reversed the agency decision denying Medicaid benefits, and remanded for a hearing before the OAL.

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