R.M. 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NOT FOR PUBLICATION WITHOUT THE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-3079-19
R.M.,
Petitioner-Appellant,
v.
DIVISION OF MEDICAL
ASSISTANCE AND HEALTH
SERVICES,
Respondent-Respondent.
__________________________
Submitted March 8, 2021 – Decided July 29, 2021
Before Judges Suter and Smith.
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 briefs).
Gurbir S. Grewal, Attorney General, attorney for
respondent (Melissa H. Raksa, Assistant Attorney
General, of counsel; Jaqueline R. D'Alessandro,
Deputy Attorney General, on the brief).
PER CURIAM
Appellant R.M. appeals the denial by the Division of Medical Assistance
and Health Services (Division) of her request for a fair hearing regarding her
July 30, 2019 application for Medicaid benefits. We affirm for the reasons set
forth below.
R.M. applied to the Division for Medicaid benefits three times in 2018 –
on February 7, April 10, and November 26. The Division denied all three
applications because she failed to provide necessary financial verifications. The
Division conducted a fair hearing on the November 26, 2018 denial, and upon
its conclusion gave R.M. additional time to supply the needed documents. R.M.
supplied them, and the Division approved the application conditioned upon
payment of a $688,418.98 transfer penalty. 1 On May 14, 2019, the Division
gave R.M. until June 3, 2019, to demonstrate that she transferred $688,418.98
in cash assets solely for reasons other than to obtain Medicaid eligibility. She
failed to meet the deadline.
1
In its letter of May 14, 2019, the Division determined that R.M. improperly
transferred $688,418.98 of her cash assets for less than fair market value. The
Division advised her that amount would "count towards her resource limit until
May 24, 2024."
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2
With no response from R.M., on June 6 the Division issued a
determination on her November 26, 2018 application, finding her eligible for
Medicaid benefits subject to the aforementioned transfer penalty. R.M. did not
immediately challenge the determination, but rather she filed a new application
for Medicaid benefits dated July 30, 2019. On August 6, 2019, the Division
informed R.M. in writing that additional documents were required to "complete"
the July 30 application.
On August 19, 2019, R.M. supplied additional information, responding to
the Division's August 6 "completeness" letter. The Division replied on
September 16, indicating their "original" June 6 determination stood, and further
noting R.M. did not "dispute [the determination] within the allotted time
frame."2 The Division advised her in its reply that it would take "no additional
action" on R.M.'s new July 30 application.
R.M. then wrote the Division on October 4, seeking a fair hearing
regarding its refusal to consider her new application. On October 25, the
Division replied in a one-page form letter, confirming the previously issued June
6 eligibility determination and advising that R.M. was "still serving her
previously imposed penalty."
2
N.J.A.C. 10:49-10.3.
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The Division subsequently denied R.M.'s October 4 fair hearing request
in a letter dated February 19, 2020, noting her request came one hundred and
twenty days after the Division's June 6 determination, making it untimely. See
supra, fn. 2. The Division characterized its October 25 letter as a
"redetermination confirming the [June 6] letter of eligibility and transfer
penalty," and "not a new determination resulting from a new Medicaid
application." It stated that giving R.M. a fair hearing on her freshly prepared
July 30 application, not her June 6 eligibility determination, would constitute "a
second bite at the apple."
R.M. appeals, arguing first that the Division erred by failing to issue a
determination regarding her July 30 application, and having refused to do so,
failed to comply with its own regulations by refusing to grant her a fair hearing
on the new application. We disagree.
Our role in reviewing an agency decision is limited. R.S. v. Div. of Med.
Assistance & Health Servs., 434 N.J. Super. 250, 260-61 (App. Div. 2014)
(citing Karins v. City of Atl. City, 152 N.J. 532, 540 (1998)). "[A]n appellate
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
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decision was not supported by substantial evidence." Ibid. (citing In re
Herrmann, 192 N.J. 19, 28 (2007)).
A presumption of validity attaches to the agency's decision. Brady v. Bd.
of Review, 152 N.J. 197, 210 (1997); In re Tax Credit Application of Pennrose
Props., Inc., 346 N.J. Super. 479, 486 (App. Div. 2002). The party challenging
the validity of the 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) (quoting In re Arenas, 385 N.J. Super. 440,
443-44 (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., 434 N.J. Super. at 261 (quoting Mayflower Sec. Co. v. Bureau of
Sec., 64 N.J. 85, 93 (1973)).
"The Medicaid program, [also known as] Title XIX of the of the Social
Security Act, is designed to provide medical assistance to persons whose income
and resources are insufficient to meet the cost of necessary care and services."
L.M. v. Div. of Med. Assistance & Health Serv., 140 N.J. 480, 484 (1995)
(citation omitted); see A.B. v. Div. of Med. Assistance & Health Serv., 407 N.J.
Super. 330, 342 (App. Div. 2009). The Legislature has designated the Division
as the entity within the Department of Human Services which "implements the
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program of medical assistance to provide necessary medical care and services
for qualified applicants" pursuant to N.J.S.A. 30:4D-5. The Division
promulgates and adopts rules and regulations to accomplish its mandate. Ibid.N.J.A.C. 10:49-10.3 requires "requests for [a fair hearing] to be made in writing
within twenty days from the date of the notice of the agency action giving rise
to [the] complaint . . . ." "[W]e must give great deference to an agency's
interpretation and implementation of its rules enforcing the statutes for which it
is responsible." In re Freshwater Wetlands Prot. Act Rules, 180 N.J. 478, 488-
89 (2004) (citation omitted).
R.M. argues first that the Division's refusal to accept and process her July
30 application was arbitrary and capricious. The Division was explicit in
multiple letters to R.M. that it decided her Medicaid benefit eligibility on June
6. She was deemed eligible at that time, subject to a transfer penalty.3 Once she
missed her opportunity to address the penalty issue by June 3, she could have
pursued a fair hearing on the June 6 eligibility decision and presented any
objections to it within twenty days. She did not do so. R.M.'s July 30
application appears to be her attempt to restart the clock, and she has made no
3
We do not reach the question of whether R.M. remedied the transfer penalty
through the restructuring of her assets after June 3, 2019, her deadline for
supplying such information to the Division.
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showing that the Division in any way failed to follow the law or was arbitrary,
capricious, or unreasonable. R.S., 434 N.J. Super. at 260-61. In fact, the
Division's actions in disregarding the July 30 application are amply supported
in the record. Ibid.
As to R.M.'s second argument, we find the Division did not err by denying
her request for a fair hearing on her rejected July 30 application. The application
itself was a nullity, which the Division was entitled to treat as legally void.
Black's Law Dictionary 1286 (11th ed. 2019).
Affirmed.
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