R.A. VS. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES (DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES) ( 2021 )

NOT FOR PUBLICATION WITHOUT THE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-1040-20
R.A.,
Petitioner-Appellant,
v.
DIVISION OF MEDICAL
ASSISTANCE AND
HEALTH SERVICES,
Respondent-Respondent.
__________________________
Submitted December 13, 2021 – Decided December 22, 2021
Before Judges Fasciale and Vernoia.
On appeal from the New Jersey Department of Human
Services, Division of Medical Assistance and Health
Services.
Bratton Law Group, attorneys for appellant (Brittany
Tedesco, on the brief).
Andrew J. Bruck, Acting Attorney General, attorney for
respondent (Melissa H. Raksa, Assistant Attorney
General, of counsel; Jacqueline R. D'Alessandro,
Deputy Attorney General, on the brief).
PER CURIAM
R.A. appeals from a November 2, 2020 final agency decision by the New
Jersey Department of Human Services, Division of Medical Assistance and
Health Services (Division), denying her untimely request for a hearing. The
Division denied R.A.'s Medicaid benefits application after she repeatedly failed
to provide the necessary verifications to establish eligibility for Medicaid
benefits. R.A. requested a hearing 273 days from the date of the denial, well
beyond the twenty-day deadline. We affirm.
On January 31, 2019, R.A. filed an application with the Division seeking
a determination for Medicaid benefits under the Aged, Blind, and Disabled
Program. The Division initially denied R.A.'s application on December 11,
2019. After R.A. provided some, but not all required materials, the Division
again denied her application on January 22, 2020, effective February 1. R.A.
was required to file her request for a hearing twenty days later. Instead, R.A.
requested an administrative hearing on October 30, 2020. The Division then
denied her request because the deadline expired.
On appeal, R.A. argues the Division failed to process her application for
Medicaid benefits. On the timeliness of her request for the hearing, R.A.
A-1040-20
2
contends that the Division did not give her proper notice of the denial of benefits,
and that it improperly rejected her request for a hearing.
At the outset, we note the question is not whether the Division failed to
process her application; it is whether R.A. made a timely request for a hearing.
Thus, the issue on appeal is whether the Division correctly denied her request
for a hearing when it determined that the request was made after the twenty-day
deadline. Our standard of review is well-settled.
"Appellate review of an agency's determination is limited in scope." K.K.
v. Div. of Med. Assistance & Health Servs., 453 N.J. Super. 157, 160 (App. Div.
2018) (quoting Circus Liquors, Inc. v. Governing Body of Middletown Twp.,
199 N.J. 1, 9 (2009)). We are bound to uphold the administrative agency
decision "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." In re Virtua-West Jersey
Hosp. Voorhees for a Certificate of Need, 194 N.J. 413, 422 (2008). "In
administrative law, the overarching informative principle guiding appellate
review requires that courts defer to the specialized or technical expertise of the
agency charged with administration of a regulatory system." Ibid. The burden
of demonstrating arbitrary, capricious, or unreasonable agency action rests on
A-1040-20
3
the party opposing the agency's action. See E.S. v. Div. of Med. Assistance &
Health Servs., 412 N.J. Super. 340, 349 (App. Div. 2010).
Under the applicable regulations, if an applicant is denied Medicaid
benefits, "[i]t is the right of every applicant . . . to be afforded the opportunity
for a fair hearing in the manner established by the policies and procedures set
forth in N.J.A.C. 10:49-10 and 10:69-6." N.J.A.C. 10:71-8.4(a). Applicants
have the right to fair hearings when their claims "are denied or are not acted
upon with reasonable promptness." N.J.A.C. 10:49-10.3(b). Requests for fair
hearings must be submitted to the Division in writing within twenty d ays of the
date of the notice of a denial, reduction, or partial denial of Medicaid benefits.
N.J.A.C. 10:49-10.3(b)(1), (3).
On December 11, 2019, the Division issued a letter initially denying
R.A.'s application under N.J.A.C. 10:71-2.2(e)(2) (permitting the denial for
failure to assist by not providing requested documentation). After R.A. received
the denial letter, she sent to the Division some of the requested information. The
Division, again, denied R.A.'s application because R.A. failed to provide
materials such as a copy of her social security card and her spouse's death
certificate. On January 22, 2020, the Division sent the second denial letter:
You have the right to request a fair hearing on this
action. You must request a fair hearing within [twenty]
A-1040-20
4
days of the date of this letter. If you have been
receiving Medicaid benefits and request a fair hearing
within the [twenty]-day period, your Medicaid benefits
may continue until a hearing decision is reached so long
as you remain eligible in all other respects. However,
if the fair hearing decision is not in your favor, you may
be required to repay any Medicaid benefits to which
you were not entitled.
Based on this letter, R.A. had until February 21, 2020 to request a fair
hearing. Rather than requesting the hearing, on January 31, 2020, R.A. sent
additional information to the Division, but did not include all the requested
documentation. Without requesting the hearing, R.A. sent follow-up emails
requesting a status update of her denied application. On October 14, 2020, an
administrator from the Camden County Board of Social Services reminded R.A.
that the application had been denied in January 2020 and indicated R.A. would
need to submit a new application. R.A. then made the untimely fair hearing
request on October 30, 2020. The Division denied the request because R.A.
made it 273 days after the Division issued the denial letter.
We reject R.A.'s contentions that the denial letters were ambiguous and
that she did not receive notice of her application's denial until October 14, 2020.
The January 22, 2020 letter stated that the Division denied her application and
she must request a fair hearing to challenge the denial within twenty days of the
letter's effective date. Accordingly, her request for a fair hearing was untimely,
A-1040-20
5
and the Division's denial of her request was neither arbitrary, capricious, or
unreasonable. In re Virtua-West Jersey Hosp., 194 N.J. at 422.
To the extent we have not addressed any remaining contentions, we
conclude that they are without sufficient merit to warrant further discussion in
a written opinion. R. 2:11-3(e)(1)(E).
Affirmed.
A-1040-20
6