E.H. VS. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES(DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES) ( 2017 )

NOT FOR PUBLICATION WITHOUT THE
APPROVAL OF THE APPELLATE DIVISION
This opinion shall not "constitute precedent or be binding upon any court."
Although it is posted on the internet, this opinion is binding only on the
parties in the case and its use in other cases is limited. R. 1:36-3.
SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
DOCKET NO. A-4560-15T2
E.H.,
Petitioner-Appellant,
v.
DIVISION OF MEDICAL ASSISTANCE
AND HEALTH SERVICES,
Respondent-Respondent.
________________________________
Submitted October 19, 2017 – Decided November 3, 2017
Before Judges Simonelli and Haas.
On appeal from the Division of Medical
Assistance and Health Services, Docket No.
091007616501.
SB2 Inc., attorneys for appellant (John P.
Pendergast, of counsel and on the briefs).
Christopher S. Porrino, Attorney General,
attorney for respondent (Lauren S. Kirk,
Deputy Attorney General, of counsel and on the
brief).
PER CURIAM
Petitioner E.H., by her designated authorized representative
(DAR), Future Care Consultants (FCC), appeals from the failure of
respondent Division of Medical Assistance and Health Services
(DMAHS) to respond to a request to transfer this matter to the
Office of Administrative Law (OAL) for a hearing.
Prior to her death in August 2015, E.H. submitted a Medicaid
application to the Hudson County Division of Welfare (HCDW), and
designated FCC as her DAR. On October 13, 2015, the HCDW denied
the application, not because of E.H.'s death, but because she
failed to provide her husband's bank records for the five-year
look-back period.
On October 29, 2015, FCC submitted to DMAHS a request for a
hearing. In a November 5, 2015 letter to FCC, DMAHS did not deny
the request; rather, it requested a copy of HCDW's denial notice.
The letter also notified FCC that the case would be closed if it
did not receive the requested information within thirty days. On
November 19, 2015, FCC sent to DMAHS a copy of the HCDW's denial
letter.
On January 25, 2016, FCC contacted DMAHS and was advised that
because E.H. had died, the fair hearing request would not be
granted until the executor of E.H.'s estate signed a DAR form.
DMAHS did not confirm this decision in writing.
FCC retained counsel, who notified DMAHS on March 24, 2016
that to his knowledge, there was no federal and State law requiring
the executor of E.H.'s estate to sign an additional DAR form to
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perfect the appeal on her behalf. Rather, counsel argued that FCC
met the federal definition of "Medicaid applicant" in 42 C.F.R. §
400.203. Counsel requested that DMAHS transmit the matter to the
OAL for a hearing. DMAHS did not respond. This appeal followed.
As a threshold issue, we first address whether FCC's request
for a fair hearing was timely. DMAHS argues the request was
untimely because FCC did not provide a copy of HCDW's denial notice
until thirty-eight days after the denial was issued. This argument
lacks merit.
N.J.A.C. 10:49-10.3(a) provides that a request for a hearing
"shall be made in writing within [twenty] days from the date the
notice of the agency action giving rise to said complaint or
issue." N.J.A.C. 10:49-10.3(b) provides as follows, in pertinent
part:
An opportunity for a fair hearing shall be
granted to all claimants requesting a hearing
because their claims for medical assistance
are denied or are not acted upon with
reasonable promptness . . . :
1. A request for hearing shall be
defined as any clear expression
(submitted in writing) by claimants (or
someone authorized to act on behalf of
claimants) to the effect that they desire
the opportunity to present their case to
higher authority;
. . . .
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3. Claimants shall have [twenty] days
from the date of notice of Medicaid Agent
or NJ FamilyCare program action in which
to request a hearing[.]
N.J.A.C. 10:49-10.3 does not require Medicaid applicant's to
provide a copy of the agency's denial notice in a written request
for a fair hearing, and DMAHS cites no authority imposing this
requirement. Similarly, the federal Medicaid regulation mandating
states to provide a fair hearing system does not specify what must
be included in a claimant's request for a fair hearing. 42 C.F.R.
431.205. Given that federal and State regulations providing for
a fair hearing do not require applicants to include a copy of the
agency's denial notice in their request within twenty days of the
contested decision, FCC's request for a fair hearing made within
sixteen days of HCDW's denial notice was timely.
Furthermore, DMAHS notified FCC that it must provide the
denial notice within thirty days of November 5, 2015. In
compliance with that deadline, FCC sent DMAHS a copy of HCDW's
denial notice fourteen days later on November 19, 2015.
Accordingly, we conclude that FCC's request for a fair hearing was
timely.
While the parties dispute whether DMAHS actually rendered a
final decision in this matter, there is no dispute that FCC did
not receive a written final decision from DMAHS or notice of its
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right to judicial review, as required by N.J.A.C. 10:49-10.10.
Likewise, DMAHS did not notify FCC, in writing, of its decision
and FCC's right to request a hearing or seek judicial review, as
required by 42 C.F.R. § 431.245(a). According to 42 C.F.R.
431.205, which outlines hearing system requirements, "[t]he
hearing system must meet the due process standards set forth in
Goldberg v. Kelly, 397 U.S. 254[, 90 S. Ct. 1011, 25 L. Ed. 2d
287] (1970)." In Goldberg, the Supreme Court held that due process
in administrative proceedings requires timely and adequate notice
and a meaningful opportunity to be heard. Id. at 267-69, 90 S.
Ct. at 1020-21, 25 L. Ed. 2d at 299. The Court specified that
notice must include the agency's reasons supporting its decision,
and an opportunity to be heard, confront witnesses, present
arguments, and submit evidence tailored to the applicant's
specific capabilities and circumstances. Ibid.We conclude that DMAHS's January 25, 2016 oral decision, even
if deemed a final decision, violated State and federal regulations
requiring written notice and notice of a right to seek State agency
or judicial review. Accordingly, we reverse the decision, and
remand for a hearing before the OAL, at which the issues raised
in this appeal shall be addressed. The parties are not precluded
from raising additional issues.
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Reversed and remanded. We do not retain jurisdiction.
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