Medicaid Applicant is Entitled to Actual Notice of Deficiencies of Application

As my readers know by now, a Medicaid application is comprised of five years’ of financial records for every single asset and transaction that occurred during the 5-year “look-back” period preceding the application, along with a host of “personal identifiers” and proofs pertaining to income, marital status, legal residency, birthdate and more. If an application is incomplete, the risk of rejection/denial is high. If the county board of social services asks for yet additional detailed proofs that are hard to come by, the risk of rejection/denial is also high. The person who takes responsibility for the application has a big job to do. Although a person can always reapply for benefits if they are still eligible, there is only a three month retroactive period, so the risk of denial can carry tremendous financial consequences.

As a matter of due process, an applicant for government benefits is entitled to actual notice of deficiencies in the application before the agency takes the severe step of denying the application. New Jersey’s regulations provide that the county welfare agency has the “responsibility” to “inform the applicants about the purpose and eligibility requirements under its provisions,” and the applicant must “assist the CWA in securing evidence that corroborates his or her statements. ” Normally, an application should be processed within 45 days, but the agency can take longer if it can be shown that the delay resulted from “a determination to afford the applicant, whose proof of eligibility has been inconclusive, a further opportunity to develop additional evidence of eligibility before final action on his or her application.” N.J.A.C. 10:71-2.3.  Also, :the eligibility worker is initially responsible for the recommendation for approval or denial.” N.J.A.C. 10:71-2.12. Taken as a whole, it can be seen that first, an application is submitted with supporting verifications, then the eligibility worker goes through it and determines what else is needed, and then the worker must communicate those needs to the applicant, because otherwise, the applicant cannot “assist” the caseworker to determine eligibility.

A recent decision illustrates that an application cannot be denied for failure to provide verifications without proof that Notice was actually provided. In R.P. v. Div. of Med. Assistance and Health Servs., [non-published, non-precedential; holding is limited to its facts].  the application was being handled by the applicant’s step-daughter. After the application was filed, the eligibility worker made oral request for certain additional documents. At a certain point, a letter was allegedly sent stating that the application was pending and would be denied for Failure to provide Necessary verifications if the documents weren’t submitted by a certain deadline. After that, the Denial was issued.  The appeal was filed within the 20-day time limit. At the hearing before an Administrative Judge (ALJ) of the Office of Administrative Law, the applicant argued that they had never received any written notice of the documents that were still needed. The ALJ found that a notice had been mailed, albeit to the wrong zipcode, and upheld the denial. The Director of Medicaid adopted that initial decision, and this appeal followed. 

The Court remanded the case for further proceedings because the record had no proof that the applicant had actually been served with Notice that the application was at risk of denial due to missing verifications.  The applicant also argued that the agency had a duty to gather up missing documents; this contention was rejected by the Court, as was done in other recent cases,  finding that the burden to produce proof of eligibility is on the applicant, not the agency.

 

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