On June 27, 2017, D.A., through his Designated Authorized Representative (DAR), applied to the Burlington County Board of Social Services, the county welfare agency (CWA), for nursing home Medicaid benefits. Prior to submitting the Medicaid application, D.A.’s nursing facility requested pre-admission screening (PAS) on D.A.’s behalf in May 2017 to establish D.A.’s clinical eligibility for Medicaid benefits.

The PAS was conducted, and D.A. was provided with written notice on July 13, 2017 finding him clinically eligible for a nursing facility level of care effective June 1, 2017. Ultimately, on July 27, 2017 D.A. was found financially eligible for Medicaid benefits, effective June 1, 2017.

On August 15, 2017, D.A.’s DAR requested a fair hearing concerning the July 27, 2017 eligibility notice. D.A. claimed that his clinical eligibility date should be backdated to April 1, 2017.

On appeal, the administrative law judge (ALJ) affirmed the CWA’s decision. At the hearing, the CWA established that the nursing facility delayed in requesting the PAS and that the PAS delay request is what caused the delay in Medicaid clinical eligibility for D.A. On April 12, 2018, the ALJ issued an initial decision and affirmed that D.A. was eligible for benefits as of June 1, 2017. The ALJ blamed the nursing facility for the delayed clinical eligibility by failing to request the PAS for D.A. on a timely basis.

On May 7, 2018, the Director of the Division of Medical Assistance and Health Services (DMAHS), the state Medicaid agency, issued a final agency decision establishing D.A.’s clinical eligibility date as June 1, 2017 and denying his request to backdate his clinical eligibility date to April 1, 2017.

D.A. appealed DMAHS’s decision to the Superior Court of New Jersey, Appellate Division. On appeal, the Superior Court of New Jersey, Appellate Division, affirmed the Director’s final agency decision, holding that since (1) the nursing facility delayed in requesting the PAS for D.A. and (2) the DAR did not submit a new application for Medicaid benefits with the Burlington County Board of Social Services until June 27, 2017, D.A. failed to establish his clinical and financial eligibility for Medicaid benefits prior to June 1, 2017.

The case is annexed here – D.A. v. Division of Medical Assistance and Health Services (App. Div.)

On December 14, 2017, D.A.’s DAR requested a fair hearing on another issue in the case, claiming that neither she nor D.A. ever received the July 13, 2017 PAS notice, confirming clinical eligibility, until December 13, 2017. No proofs or documentation were submitted by the DAR to show that the PAS was not received.

On December 26, 2017, DMAHS denied D.A.’s request for a hearing because the appeal was not timely filed. D.A. appealed. On appeal, the sole issue was whether DMAHS reasonably denied D.A.’s December 14, 2017 hearing request relative to the July 13, 2017 notice as untimely. Both the ALJ and the Director of Medicaid held in favor of the the CWA. D.A. again appealed.

The Superior Court of New Jersey, Appellate Division, held that the Medicaid regulations clearly establish that a petitioner must submit a timely request a fair hearing, otherwise the opportunity to appeal is foreclosed. The court held that the CWA provided notice to D.A. and hand-delivered the July 13, 2017 notice to D.A.’s nursing facility on that date because nothing was presented by D.A. to refute the assumption of proper service. Therefore, the court concluded that DMAHS did not act arbitrarily, capriciously, or unreasonably in applying Medicaid eligibility regulations to deny D.A.’s hearing request.

The case is attached here – D.A. v. Division of Medical Assistance and Health Services (App. Div.) SB2, INC.

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