Reduction in Care Services Rejected Unless Supported by Improvements in Recipient’s Medical Condition

Plaintiff, D.W., is a 48 year-old woman with Down’s Syndrome and the mental capacity of a 4-year-old. She requires care 24 hours per day, 7 days per week. She resides with her sister who works full-time.

D.W. participates in the Personal Preference Program (PPP) administered by the Division of Medical Assistance and Health Services (DMAHS). In 2009, D.W. was approved for a monthly cash grant covering 40 hours per week of Personal Care Assistant services. D.W.’s participation in the PPP program was reassessed in September 2012, and then again in early 2013. As a result, the 40 hours per week in Personal Care Assistant services granted in 2009 was reduced to 25 hours per week. A notice of reduction was issued, and D.W. appealed, requesting a hearing in order to challenge the reduction.

After the hearing, the administrative law judge (ALJ) concluded that D.W.’s deteriorating medical condition militated against a reduction in benefits. The DMAHS took exception to the ALJ’s decision and appealed to the Director of DMAHS, who ultimately issued a final agency decision concluding that 25 hours per week of Personal Care Assistant services was medically necessary and appropriate. D.W. appealed the final agency decision to the Superior Court of New Jersey, Appellate Division.

The Court found that the Director’s decision could not logically be sustained in the absence of an explanation of how a reduction of Personal Care Assistant services was warranted where it was undisputed that D.W.’s medical condition had deteriorated since 2009 when the DMAHS had determined that she needed 40-hours per week of support. Accordingly, the Director’s decision was vacated and the matter was remanded for reconsideration.

The case is attached here –  D.W. v. Division of Medical Assistance and Health Services, App. Div. (per curiam)

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