Persistance paid off for Eligible Medicaid Applicant

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

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