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 Assistance and Health Servs., [non-published, non-precedential; holding is limited to its facts].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.

 

Call us for representation on Medicaid Applications, eligibility plans, fair hearings and appeals ……. 732-382-6070

 

 

 

 

Medicaid applicant must prove that funds in Joint account were contributed by other co-owner

An applicant for Medicaid to pay for nursing home care is not eligible if the available resources exceed a certain level. The regulations for New Jersey Medicaid specify how joint accounts are treated: “All funds in the account are resources to the individual, so long as he or she has unrestricted access to the funds (that is, an “or” account) regardless of their source. When the individual’s access to the account is restricted (that is, an “and” account), the CWA [caseworker] shall consider a pro rata share of the account toward the appropriate resource maximum, unless the client [applicant] and the other owner demonstrate that actual ownership of the funds is in a different proportion.” N.J..A.C 10:71-4.1(d)2.

The burden of proof is on the applicant, and since this is an administrative proceeding, the burden is the mere preponderance of the evidence. However, applicants should always be prepared to provide specific, orderly, non-hearsay evidence which has extra corroboration if possible.  Live testimony is often important. If an application is denied, the applicant can seek a Fair Hearing before the Office of Administrative Law. The Director of the NJ Division of Medical Assistance and Health Services makes the final determination and then either party can appeal to the Appellate Division.

In a recent non-precedential decision called S.M. v. Div. of Med. Assistance and Health Serv., N.J. Super. App. Div. (per curiam), the Agency had rejected an application for Medicaid benefits because of a joint bank account she owned with her son. The amount in the account was $70,000, but her resource limit for eligibility was $2,000. She claimed that $60,000 of the funds was contributed by her son when he sold his house. The Administrative Law Judge apparently found the son to lack credibility, and apparently there were gaps in the evidence. The denial was confirmed by both the Judge and the Agency director, but the Court found that this decision didn’t rest on “substantial evidence in the record” and a remand was necessary to address the unresolved gaps in the evidence. The case was remanded for further proceedings.

Moral of the story: gather ye evidence while ye may. It’s necessary to put together an orderly, strong legal case for that first administrative proceeding. This is no guarantee of success with DMAHS, which often reverses favorable ALJ decisions, but it can make for a sturdier record as the case moves through the appellate process.

Call us for advice on Medicaid eligibility and for representation in Medicaid  Fair Hearings and Appeals ……. 732-382-6070