Plaintiff Stated A Claim Under The ADA When NJ Refused To Raise The Income Cap Which Excluded Him From A Community Medicaid Program

In Duffy v. Velez, Civ. No. 09 – 5539 (D.N.J. 2010), plaintiff was a disabled person who received needs-based government benefits, including Medicaid benefits while in the community. The availability of the benefits was based upon an applicant’s income. Individuals who earn up to $2,022 per month are eligible for benefits at the “categorically needy” level. People who earn more than $2,022 per month may be eligible for benefits at the “medically needy” level. While he lived at home, plaintiff received Medicaid benefits at the “medically needy” level. One of the programs available at the “categorically needy” level was the “Global Options for Long-Term Care” program (Global Options).

After his health declined, plaintiff moved into a Medicaid-certified hospital and was place on the waiting list for an assisted living facility (ALF). The ALF accepted plaintiff as a resident under Global Options and plaintiff moved into the facility. Months later, plaintiff was informed by the local County Board of Social Services (CBOSS) that plaintiff’s income exceeded the “categorically needy” level by $10 per month and plaintiff was therefore ineligible for Global Options. Plaintiff asked that the State make an exception to the income cap limitation, but the request was denied. As a result, plaintiff was transferred to a nursing home because in NJ there is no income cap for the nursing home Medicaid program.

Plaintiff filed a lawsuit in federal district court in New Jersey, claiming that the State’s refusal to make an exception to the income cap for benefits available at the “categorically needy” level constituted a failure to make a reasonable accommodation for a disabled individual in violation of the Americans With Disabilities Act (ADA). Instead of filing an answer to plaintiff’s complaint, the State filed a motion to dismiss, claiming that plaintiff failed to state a claim upon which relief could be granted.

The Court’s job in response to a motion to dismiss is “to determine whether the facts alleged in the complaint are sufficient to show that the plaintiff has a ‘plausible claim for relief.’” The Court found that, under the ADA, the State had a duty to administer services, programs, and activities appropriate for the needs of disabled persons in an “integrated setting”, or a setting that “enables individuals with disabilities to interact with nondisabled persons to the fullest extent possible.” Here, the Court found that, since the State denied his request for an exception to the “categorically needy” income cap, plaintiff had stated a claim under the ADA for failure to accommodate his disability. If granted, the accommodation would have allowed plaintiff to obtain the medical care to which he was entitled in a setting less restrictive than a nursing home. As a result, the State’s motion to dismiss was denied.

The Duffy case is annexed here – Duffy v. Velez – Opinion and Order