Here is a recent case that is interesting because of its detailed description of the prolonged delay in the processing of an application for MLTSS Medicaid benefits, which was followed by the agency’s failure to really look at the information submitted and an abrupt denial of benefits that could have caused horrendous consequences. The Appellate Division reversed, in a decision that is not approved for publication so it is not binding on other courts, but is a good illustration of what can happen in the Medicaid application process.
In W.M. vs DMAHS, the available resources of W.M. and his wife were below the $119,240 resource limit at the time he applied for Medicaid benefits on December 1, 2013 to pay for his nursing home costs. They had spent down large sums from his Pacific Life insurance policy, then surrendered it and deposited the proceeds into their bank account where some of it was used for further spend-down. The couple’s remaining assets included several policies of small value and money in the bank. A month later, the County Board of Social Services requested certain additional verifications, which were promptly supplied. The couple’s representative kept contacting the Board for a year, and heard nothing. Finally in February and in March, 2015, the caseworker sent additional information requests, which were supplied, and the case was then “abruptly” provisionally Denied on April 15, 2015 in a letter that invited them to submit more proof, which they did. A letter dated April 28 asked for further clarification which was supplied on the 30th. The Board reiterated its Denial and the request for Fair Hearing followed.
The issues at the Fair Hearing centered on whether the applicant had produced the necessary verifications in timely response to requests, and just what it was that the agency felt was inadequate about the verifications (proof) that were produced. The Administrative Law Judge found that “had they examined the document more closely,” the Board would have seen all the information they kept asking for, including the evidence that it had been surrendered before the application was filed. Further, “it is uncontroverted” that WM was eligible at the time the application was filed. The ALJ recommended reversal of the denial. The Director remanded the decision and focused on whether AM had “timely responded to requests.” On remand, the ALJ further found that everything necessary had been supplied in a timely way. Nonetheless, the DMAHS reversed, finding that proofs concerning certain small policies had not been timely produced.
The Appellate Division reversed, and found that it was “unrefuted” that W.M. was eligible; that the policies which the County kept asking about had “as the [Board] knew, only minimal value and were incapable of disqualifying him,” and the agency’s “persistence in denying this meritorious application” was ‘arbitrary, capricious and unreasonable.”
For advice and assistance in preparing and filing Medicaid applications for MLTSS, call us at .. 732-382-6070
On July 12th we reported that a bill to improve and streamline the Medicaid application process was on the Governor’s desk. The bill was signed recently. Here’s the NJ Bar Association’s press release. Lauren Marinaro worked along with other colleagues in NJ NAELA to help get this bill passed.
This new law (S-499/A4569) is a good start towards evaluating and implementing procedures that can improve the experience that the public has when they need to apply for Medicaid benefits for long-term care. As regular readers of this blog know, applying for MLTSS is often a harrowing experience and applicants encounter many frustrating proof requirements that can be difficult if not impossible to meet. The bill appoints a Medicaid eligibility ombudsperson to receive complaints, as well as liberalizes requests for more time to retrieve documents in the application process.
Look for more updates here on the Murphy administration’s implementation of this new law!
For advice on MLTSS Medicaid applications and appeals, call us at … 732-382-6070
The burden to prove eligibility for Medicaid rests with the applicant, but sometimes, the agency just refuses to accept the evidence they are given. This is demonstrated in a recent New Jersey case in which a denial of benefits was reversed by the Appellate court. The decision is “not approved for publication ,” which means it doesn’t establish a precedent that’s binding on other courts, but it does provide an interesting view of what can happen in a case. L.A. vs DMAHS decision
L.A and her husband established a revocable living trust for their own benefit, and transferred their house into it. Their Social Security numbers were associated with this trust. An attorney wrote the trust. The Asset Schedule at the back of the Trust document wasn’t filled out, so nothing was shown as to the assets that were placed into the trust. Some years later, in 2012, the trustees transferred the property out of the trust into the names of L.A. and her husband. In 2017, the couple terminated the Trust — which held no assets and apparently no longer had any purpose — and transferred the house into L.A.’s sole name. Later, a Medicaid application was filed for L.A. They didn’t disclose the Trust when they provided the 60-month look-back documents. For the look-back, one must submit records of all assets held within the prior 60 months. As noted, the Trust had not held any assets during the look-back period. The agency reviewed the Deed and asked for the Trust records. The applicant submitted the trust document, the trust termination document, and a letter from their attorney which stated that the only asset that was ever in the Trust was the house. As noted above, Schedule A to the trust was blank, so no assets were listed on the Trust. The application was denied for “failure to submit required verifications” of the assets in the trust. L.A. requested a fair hearing appeal before the Office of Administrative Law (OAL).
At the hearing before the Administrative Law Judge (ALJ), the attorney who wrote the trust testified in accordance with the letter he had written for the application, and explained that the annexed Schedule was left blank because it called for information not applicable to the situation. Both he and L.A.’s husband testified that the house was the only asset that was ever in the Trust. Tax return evidence was submitted which did not show income from any trust assets. The ALJ concluded that they were credible, but that the explanation about the blank schedules was inadequate and that plaintiff had indeed failed to submit the “required verifications” to establish Medicaid eligibility, and upheld the denial of benefits. The DMAHS adopted that decision, and L.A. appealed, represented by our Firm. Essentially, the Final Agency Decision stood for the proposition that even when there is no proof of assets, the agency may presume that they exist, and may deny eligibility for failure to prove otherwise.
On appeal, the court reversed, ruling that the final agency decision was not supported by the record. An administrative agency must base its decision on the “substantial credible evidence” in the case record, and the appellate court can overrule an agency decision if it is based on “findings that are contrary to the record.” The court noted that the agency “reviewed the application with skepticism” despite the explanations, and despite that information, “speculated” that additional assets were in the trust, leading to a situation in which “L.A. was required to produce information that simply did not exist” The Court reversed the denial, and held that “L.A. supplied all the necessary information for review of her application, and that her benefits should not have been denied because of the omission” of evidence that simply does not exist.
The Medicaid application process is a minefield with many traps for the unwary. As individuals grow older they need to always be looking to the future when they set up their financial arrangements, maintain their paperwork and handle their accounts and trusts, because things can turn on a dime and it just might become necessary to prove one’s eligibility for Medicaid. We’re here to help at every step of the way.
Call for advice and representation concerning Medicaid planning, applications and appeals ……. 732-382-6070
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