H.T. was admitted to a nursing home in Union City, NJ. Soon thereafter, a Medicaid application for the Nursing Home Medicaid program was filed on H.T.’s behalf.

Under the Medicaid regulations, applicants for the Nursing Home Medicaid Program must be found clinically eligible to qualify for benefits. After an evaluation by the Medicaid agency to determine if she was clinically eligible, H.T. was found clinically ineligible for the program. However, H.T. never received written notification of the agency’s finding of clinical ineligibility until many months later, and only after her counsel made a formal request for status for the clinical eligibility determination.

Because an applicant must not only qualify clinical eligibility for the Nursing Home Medicaid program but also must establish financial eligibility, the Medicaid agency asked H.T. to provide additional financial information and bank records. Upon receipt of the information, the agency denied H.T.’s claim because H.T.’s “[g]ross income exceed[ed] 100% of [the] poverty level.” The letter notified H.T. that an appeal for a fair hearing must be requested within twenty days. Notably, however, rather than referring to the Nursing Home Medicaid program to which H.T. applied, the agency’s denial letter referred to a different Medicaid program, the “NJ Care Special Medicaid Program.”

H.T. filed a timely appeal for a fair hearing of the denial of benefits under the NJ Care Special Medicaid Program. A fair hearing was held before an Administrative Law Judge (ALJ) but, before a decision was issued, H.T. submitted a request for a fair hearing to challenge the determination that H.T. was clinically ineligible for the Nursing Home Medicaid program.

The ALJ issued an initial decision affirming the denial of benefits. The ALJ explained that H.T. was found clinically ineligible for the Nursing Home Medicaid Program by the agency and was then found financially ineligible for the NJ Care Special Medicaid Program because H.T.’s “income exceeded the limits . . .” The agency issued its Final Agency Decision which adopted the ALJ’s initial decision.

H.T. filed an appeal to the Superior Court of New Jersey, Appellate Division, asserting that the Medicaid agency mistakenly denied eligibility for the NJ Care Special Medicaid Program, which she had never applied for, rather than considering her clinical eligibility for the Nursing Home Medicaid Program, which she had applied for. As to her claim under the Nursing Home Medicaid Program, she maintained that she never received a letter denying benefits due to clinical ineligibility, and the Division’s failure to schedule a hearing after she filed an appeal months later was an abuse of discretion.

The Appellate Division found that the Medicaid agency did not abuse its discretion when it determined that H.T. was financially ineligible for the NJ Care Special Medicaid Program. After requesting financial information from H.T., the agency found that H.T. was financially ineligible “because her income exceeded 100 of the poverty level …” H.T. did not challenge that finding by way of competent evidence. As a result, the court held that there was no basis to disturb the Final Agency Decision.

With respect to the agency’s failure to act on H.T.’s late request for a fair hearing on the finding that she was clinically ineligible for the Nursing Home Medicaid Program, the appeals court held that a remand was necessary so that the ALJ could develop a factual record regarding H.T.’s receipt of the letter denying clinical eligibility. The court found that “the record is devoid of a certification of service, or testimony regarding the [agency’s] practice and procedure in mailing correspondence by regular mail. The [agency] has furnished no corroborating proof of mailing customs, either in an appellate appendix or the statement of items comprising the record …”

The case is attached here – H.T, v DMAHS

For additional information concerning Medicaid applications and appeals, visit:

NJ Medicaid Applications

For additional information concerning Medicaid and public benefits planning, visit:

NJ Medicaid and Public Benefits Planning

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