G.M. VS. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES (DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES) ( 2019 )

NOT FOR PUBLICATION WITHOUT THE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-5444-17T2
G.M.,
Petitioner-Appellant,
v.
DIVISION OF MEDICAL
ASSISTANCE AND HEALTH
SERVICES and ATLANTIC
COUNTY BOARD OF
SOCIAL SERVICES,
Respondents-Respondents.
____________________________
Submitted October 22, 2019 – Decided November 12, 2019
Before Judges Currier and Firko.
On appeal from the New Jersey Department of Human
Services, Division of Medical Assistance and Health
Services.
Cowart Dizzia, LLP, attorneys for appellant (Jenimae
Almquist, on the briefs).
Gurbir S. Grewal, Attorney General, attorney for
respondent Division of Medical Assistance and Health
Services (Melissa H. Raksa, Assistant Attorney
General, of counsel; Jacqueline R. D'Alessandro,
Deputy Attorney General, on the brief).
PER CURIAM
Petitioner G.M. appeals from the final agency decision of respondent
Division of Medical Assistance and Health Services (Division) finding him
ineligible for Medicaid benefits. We affirm.
The record in this case reveals petitioner is approximately seventy-three
years old, has been diagnosed with Alzheimer's disease, vascular dementia,
schizoaffective and bipolar disorders, and he suffered a stroke. On December
19, 2016, the Atlantic County Board of Social Services (Board) notified
petitioner that his application was denied because he did not provide the
necessary information.
On April 27, 2017, petitioner's designated authorized representative
(DAR) submitted a second application for Medicaid benefits on behalf of G.M.
By letter dated May 8, 2017, the Board requested information from UBS
confirming there was no balance remaining in G.M.'s pension plan, and the
Board sought copies of G.M.'s Wells Fargo bank statements for his account
ending in 1531 from March 2016 to the present time, which was the account
disclosed on his application.
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After not receiving the requested information, the Board sent a letter on
June 12, 2017, stating the requested information was required within ten days to
avoid denial of G.M.'s Medicaid application. A ten-day extension was requested
on behalf of G.M. and the Board extended the deadline to July 5, 2017. G.M.'s
counsel requested a further deadline extension in a July 3, 2017 letter explaining:
As you know, Wells Fargo requested additional signed
and notarized paperwork on June 5, 2017; those forms
have been sent out and we are awaiting a response.
With respect to the UBS verification, this office has
made daily calls and multiple letter requests to UBS[,]
most recently on June 30, 2017 and July 3, 2017. After
multiple calls on July 3 in anticipation of the deadline,
UBS advised me by phone that [G.M.'s] account has a
negative balance and is inactive. UBS also advised that
it sent out a recent statement to [G.M.'s] address but
that statement has not yet been received. Finally, UBS
advised that any additional statements would require a
Doctor's note and Affidavit of Agent. We will work on
obtaining this documentation.
In response, the Board again extended the deadline to July 15, 2017,
cautioning that G.M.'s Medicaid application would be denied if the requested
information was not forthcoming, and a new application would have to be
submitted.
On July 14, 2017, G.M.'s counsel requested the Board stay the processing
of his Medicaid application pending the appointment of a guardian for G.M.,
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who was unable to assist in processing the application. 1 The letter advised that
C.M.M., who is G.M.'s sister and power-of-attorney (POA), lost several
documents and was unable to provide the authorizations requested by Wells
Fargo and UBS. After not receiving the requested information within the
requested time frame, on July 17, 2017, the Board denied G.M.'s second
application under N.J.A.C. 10:71-2.2(e).
Petitioner requested a fair hearing and the matter was transferred to the
Office of Administrative Law (OAL) as a contested case. While the hearing was
pending, the DAR provided a UBS statement and a statement from a Wells Fargo
account ending in 7175, which were not previously disclosed. An
Administrative Law Judge (ALJ) conducted a hearing on April 18, 2018. During
the hearing, the Board provided explanations for its denial of G.M.'s Medicaid
application. No testimony was offered by the DAR. The DAR relied upon her
pre-hearing summary detailing the attempts made to obtain the information from
Wells Fargo, UBS, and G.M.'s sister, C.M.M., who was ill, and could not locate
the relevant documents.
1
On December 21, 2017, Thomas Haynes, Esq. was appointed temporary
guardian of G.M. On February 1, 2018, Carl Goloff, Esq. was appointed
permanent guardian of G.M.
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The ALJ issued an initial decision affirming the denial of petitioner's
Medicaid eligibility and stating the DAR presented insufficient evidence that
the necessary verifications could not be obtained "due to some medical disability
or incapacity of [C.M.M.]." Further, the ALJ determined that C.M.M. and the
DAR "should have been able to provide the requisite verifications . . . ."
On June 14, 2018, the Division adopted the ALJ's findings, stating the
Board granted "numerous extensions of time to provide the information that
could not be obtained through any verification system[,]" and the claim that
C.M.M. was incapacitated "is not supported by the record."
This appeal followed. The DAR argues that G.M. and C.M.M.'s
compromised medical conditions rendered denial of G.M.'s medical application
in eighty-one days contrary to state and federal law, the Board had a duty to
assist G.M. by processing his application, and the determination of his Medicaid
ineligibility was arbitrary, capricious, and unreasonable.
Appellate review of the Division's final agency action is limited. K.K. v.
Div. of Med. Assistance & Health Servs., 453 N.J. Super. 157, 160 (App. Div.
2018). We "defer to the specialized or technical expertise of the agency charged
with administration of a regulatory system." In re Virtua-West Jersey Hosp.
Voorhees for a Certificate of Need, 194 N.J. 413, 422 (2008). "[A]n appellate
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court ordinarily should not disturb an administrative agency's determinations or
findings unless there is a clear showing that (1) the agency did not follow the
law; (2) the decision was arbitrary, capricious, or unreasonable; or (3) the
decision was not supported by substantial evidence." Ibid.
A presumption of validity attaches to the agency's decision. See Brady v.
Bd. of Review, 152 N.J. 197, 210 (1997). The party challenging the validity of
an agency's decision has the burden of showing that it was arbitrary, capricious,
or unreasonable. J.B. v. N.J. State Parole Bd., 444 N.J. Super. 115, 149 (App.
Div. 2016) (citing Aqua Beach Condo. Ass'n v. Dep't of Cmty. Affairs, 186 N.J.
5, 15-16 (2006)). "Deference to an agency decision is particularly appropriate
where interpretation of the Agency's own regulation is in issue." I.L. v. Div. of
Med. Assistance & Health Servs., 389 N.J. Super. 354, 364 (App. Div. 2006).
However, "an appellate court is 'in no way bound by the agency's interpretation
of a statute or its determination of a strictly legal issue.'" R.S. v. Div. of Med.
Assistance & Health Servs., 434 N.J. Super. 250, 261 (App. Div. 2014) (quoting
Mayflower Sec. Co. v. Bureau of Sec. in Div. of Consumer Affairs of Dep't of
Law & Pub. Safety, 64 N.J. 85, 93 (1973)).
Medicaid is a federally-created, state-implemented program that provides
"medical assistance to the poor at the expense of the public." Estate of
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DeMartino v. Div. of Med. Assistance & Health Servs., 373 N.J. Super. 210,
217 (App. Div. 2004) (quoting Mistrick v. Div. of Med. Assistance & Health
Servs., 154 N.J. 158, 165 (1998)); see also 42 U.S.C. § 1396-1. Although a state
is not required to participate, once it has been accepted into the Medicaid
program it must comply with the Medicaid statutes and federal regulations. See
Harris v. McRae, 448 U.S. 297, 301 (1980); United Hosps. Med. Ctr. v. State,
349 N.J. Super. 1, 4 (App. Div. 2002); see also 42 U.S.C. § 1396a(a) and (b).
The state must adopt "'reasonable standards . . . for determining eligibility for
. . . medical assistance . . . [that are] consistent with the objectives' of the
Medicaid program[,]" Mistrick, 154 N.J. at 166 (first alteration in original)
(quoting L.M. v. Div. of Med. Assistance & Health Servs., 140 N.J. 480, 484
(1995)), and "provide for taking into account only such income and resources as
are . . . available to the applicant." N.M. v. Div. of Med. Assistance & Health
Servs., 405 N.J. Super. 353, 359 (App. Div. 2009) (quoting Wis. Dep't of Health
& Family Servs. v. Blumer, 534 U.S. 473, 479 (2002)); see also 42 U.S.C. §
1396a(a)(17)(A)-(B).
New Jersey participates in the federal Medicaid program pursuant to the
New Jersey Medical Assistance and Health Services Act, N.J.S.A. 30:4D-1 to
-19.5. Eligibility for Medicaid in New Jersey is governed by regulations adopted
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in accordance with the authority granted by N.J.S.A. 30:4D-7 to the
Commissioner of the Department of Human Services (DHS). The Division is
the agency within the DHS that administers the Medicaid program. N.J.S.A.
30:4D-5, -7; N.J.A.C. 10:49-1.1. Accordingly, the Division is responsible for
protecting the interests of the New Jersey Medicaid Program and its
beneficiaries. N.J.A.C. 10:49-1.1(b).
N.J.A.C. 10:71-2.2(c) requires Board caseworkers to "[a]ssist the
applicants in exploring their eligibility for assistance[,]" and N.J.A.C. 10:71-
2.10(a) and (b) require Board caseworkers to conduct a "collateral investigation"
to "verify, supplement or clarify essential information." The DAR argues the
Board failed to contact his financial institutions to verify his resources, and
therefore, erroneously denied his application.
The DAR's argument, however, ignores N.J.A.C. 10:71-2.2(e), which
provides:
As a participant in the application process, an applicant
shall:
1. Complete, with assistance from the Board if needed,
any forms required by the Board as part of the
application process;
2. Assist the Board in securing evidence that
corroborates his or her statements; and
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3. Report promptly any change affecting his or her
circumstances.
We agree with the Division's conclusion that nothing in the record shows
the Board failed to assist G.M. Moreover, as the ALJ noted, the Board "granted
numerous extensions of time" to G.M. to provide the information that could not
be obtained through any verification system. G.M.'s documents were mailed to
his sister C.M.M. as his POA and no evidence was produced to prove she was
incapacitated.
Applying the governing standards of review and legal principles, we
conclude the Director's findings are supported by sufficient credible evidence in
the record, and that the final agency decision was not arbitrary, capricious, or
unreasonable. On the contrary, the final agency decision sustaining the denial
of petitioner's Medicaid eligibility was appropriate.
Affirmed.
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