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

NOT FOR PUBLICATION WITHOUT THE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-1183-17T4
R.A.,
Petitioner-Appellant,
v.
DIVISION OF MEDICAL ASSISTANCE
AND HEALTH SERVICES and CAMDEN
COUNTY BOARD OF SOCIAL SERVICES,
Respondents-Respondents.
______________________________________
Submitted October 22, 2018 – Decided October 29, 2018
Before Judges Fasciale and Gooden Brown.
On appeal from the New Jersey Department of Human
Services, Division of Medical Assistance and Health
Services.
Cowart Dizzia LLP, attorneys for appellant Deptford
Center for Rehabilitation and Healthcare (Lycette
Nelson, 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; Patrick Jhoo, Deputy Attorney
General, on the brief).
PER CURIAM
R.A. appeals from a September 13, 2017 final agency decision by the
Department of Human Services Division of Medical Assistance and Health
Services (DMAHS) concluding that R.A. failed to provide financial
verifications after receiving multiple requests by the county welfare agency
(CWA). The agency concluded that the CWA was unable to complete its
eligibility determination because of R.A.'s failure to produce the required
information. We affirm.
In January 2016, R.A.'s son and designated representative, C.A., filed
R.A.'s Medicaid application. One month later, the CWA advised C.A. that the
application was incomplete, and requested that C.A. produce additional
information including verifications of R.A.'s financial resources by March 12,
2016. In April 2016, the CWA requested verification as to the source of a
deposit to a bank account on June 20, 2013, in the amount of $4556. The CWA
requested the missing information and verifications so that it could determine
whether R.A. was eligible for Medicaid. C.A. failed to produce the information
by a new deadline of April 28, 2016.
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The CWA then extended the deadline to May 13, 2016. The CWA learned
that the $4556 deposit related to the sale of R.A.'s home, and requested the house
appraisal, a settlement check, and proof of how the sale proceeds were spent.
C.A. failed to provide the requested information by an extended deadline of June
23, 2016. The CWA then denied the application on June 29, 2016. The notice
of denial erroneously indicated that the deposit at issue was made on July 22,
2013 rather than June 20, 2013, but in December 2016, the CWA issued a revised
notice of denial correcting that mistake.
An administrative law judge (ALJ) conducted a hearing and issued an
initial decision upholding the CWA's denial of the application. The ALJ found
that C.A. failed to produce the missing information and missed the multiple
deadlines. The ALJ concluded that R.A. violated N.J.A.C. 10:71-2.2(e).
The Director of DMAHS then issued the final decision adopting the ALJ's
findings and conclusions. She reviewed the entire record and noted neither party
filed exceptions. She acknowledged that the only issue is whether R.A. provided
the necessary verifications for the CWA to make an eligibility determination.
The Director found that "[t]he credible evidence in the record demonstrates that
[R.A.] failed to provide the needed information prior to the June 29, 2016 denial
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of benefits. Without this information, the [CWA] was unable to complete its
eligibility determination and the denial was appropriate."
On appeal, R.A. argues that DMAHS erred by basing its decision on a
void notice dated June 29, 2016, rather than one dated in December 2016; by
upholding the denial of the application because R.A. produced the missing
information; and for the first time, R.A. contends that a witness testified without
being under oath.
We begin by addressing our standard of review and general governing
legal principles. This court's review of DMAHS's determination is limited.
Barone v. Dep't of Human Servs., Div. of Med. Assistance & Health Servs., 210
N.J. Super. 276, 285 (App. Div. 1986) (explaining that "we must give due
deference to the views and regulations of an administrative agency charged with
the responsibility of implementing legislative determinations"); see also Wnuck
v. N.J. Div. of Motor Vehicles, 337 N.J. Super. 52, 56 (App. Div. 2001)
(indicating that "[i]t is settled that [a]n administrative agency's interpretation of
statutes and regulations within its implementing and enforcing responsibility is
ordinarily entitled . . . deference") (second alteration in original) (citations and
internal quotation marks omitted).
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We have previously stated that "[w]here [an] action of an administrative
agency is challenged, a presumption of reasonableness attaches to the action of
an administrative agency[,] and the party who challenges the validity of that
action has the burden of showing that it was arbitrary, unreasonable or
capricious." Barone, 210 N.J. Super. at 285 (citation and internal quotation
marks omitted). "Delegation of authority to an administrative agency is
construed liberally when the agency is concerned with the protection of the
health and welfare of the public." Ibid. Thus, our task is limited to deciding
(1) whether the agency's decision offends the State or
Federal Constitution; (2) whether the agency's action
violates express or implied legislative policies; (3)
whether the record contains substantial evidence to
support the findings on which the agency based its
action; and (4) whether in applying the legislative
policies to the facts, the agency clearly erred in
reaching a conclusion that could not reasonably have
been made on a showing of the relevant factors.
[A.B. v. Div. of Med. Assistance & Health Servs., 407
N.J. Super. 330, 339 (App. Div. 2009) (citation
omitted).]
The Medicaid program was created when Congress added Title XIX to the
Social Security Act, 42 U.S.C.A. §§ 1396 to 1396w-5, "for the purpose of
providing federal financial assistance to States that choose to reimburse certain
costs of medical treatment for needy persons." Harris v. McRae, 448 U.S. 297,
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301 (1980). Participation in the Medicaid program is optional for states;
however, "once a State elects to participate, it must comply with the
requirements of Title XIX." Ibid. The New Jersey Medical Assistance and
Health Services Act, N.J.S.A. 30:4D-1 to -19.5, authorizes New Jersey's
participation in the Medicaid program.
The Commissioner of the New Jersey Department of Human Services has
the power to issue regulations dealing with eligibility for medi cal assistance.
N.J.S.A. 30:4D-7. DMAHS is a division of the Department of Human Services
that operates the Medicaid program in New Jersey. N.J.S.A. 30:4D-4. The
CWA grants or denies applications for Medicaid benefits. N.J.A.C. 10:71-3.15.
Pursuant to this regulation, a CWA must determine "income and resource
eligibility." N.J.A.C. 10:71-3.15(a). N.J.A.C. 10:71-4.1(b) defines resource to
include
any real or personal property which is owned by the
applicant (or by those persons whose resources are
deemed available to him or her, as described in
N.J.A.C. 10:71-4.6) and which could be converted to
cash to be used for his or her support and maintenance.
Both liquid and non[-]liquid resources shall be
considered in the determination of eligibility, unless
such resources are specifically excluded under the
provisions of N.J.A.C. 10:71-4.4(b).
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The regulation explains that a resource must be "available" to be
considered in determining eligibility. N.J.A.C. 10:71-4.1(c). A resource is
"available" when: "1. [t]he person has the right, authority or power to liquidate
real or personal property or his or her share of it; 2. [r]esources have been
deemed available to the applicant ([pursuant to] N.J.A.C. 10:71-4.6 . . .); or 3.
[r]esources arising from a third-party claim or action" under certain
circumstances. Ibid. The value of the resource is "defined as the price that the
resource can reasonably be expected to sell for on the open market in the
particular geographic area minus any encumbrances (that is, its equity value)."
N.J.A.C. 10:71-4.1(d). The regulation explains that "[t]he CWA shall verify the
equity value of resources through appropriate and credible sources." N.J.A.C.
10:71-4.1(d)(3). "Resource eligibility is determined as of the first moment of
the first day of each month." N.J.A.C. 10:71-4.1(e).
In delineating the responsibilities in the application process, the regulation
states that the applicant is required to "[c]omplete, with assistance from the
CWA if needed, any forms required by the CWA as a part of the application
process." N.J.A.C. 10:71-2.2(e)(1). Moreover, the applicant is expected to
"[a]ssist the CWA in securing evidence that corroborates his or her statements."
N.J.A.C. 10:71-2.2(e)(2). "The process of establishing eligibility involves a
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review of the application for completeness, consistency, and reasonableness."
N.J.A.C. 10:71-2.9. Retroactive eligibility for Medicaid is governed by the
regulation and allows "outstanding unpaid medical bills incurred within the
three month period prior to the month of application" to be compensated upon
approval by the agency. N.J.A.C. 10:71-2.16(a).
Finally, and important to this appeal, the regulation notes that
"[e]ligibility must be established in relation to each legal requirement to provide
a valid basis for granting or denying medical assistance" and that an applicant's
statements regarding eligibility are "evidence." N.J.A.C. 10:71-3.1(a), (b).
"Incomplete or questionable statements shall be supplemented and substantiated
by corroborative evidence from other pertinent sources, either documentary or
non[-]documentary." N.J.A.C. 10:71-3.1(b). Thus, these regulations establish
that an applicant must provide sufficient documentation to the agency to allow
it to determine eligibility and corroborate the claims of the applicant.
The CWA provided R.A.'s representative with three written notices that
she must provide verifications of her financial resources: February 26, 2016,
April 13, 2016, and June 8, 2016. From the date of her initial application in
January 2016 to her denial in June 2016, R.A. was allowed 166 days to provide
verifications that were requested three times. The CWA extended the deadlines,
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and clearly informed R.A. that the final deadline was June 23, 2016. Yet, R.A.
failed to meet the final deadline.
We reject R.A.'s contention that DMAHS erred by basing its decision on
the notice dated June 29, 2016, rather than December 2016. R.A. argues that
the June 29, 2016 notice is void because it misidentified the transaction; it
indicated that the deposit was made on July 22, 2013, instead of June 20, 2013.
Consequently, she asserts the misidentification deprived her of proper notice of
what information was outstanding before the CWA could determine eligibility.
But while the application was pending, the CWA notified R.A. on multiple
occasions about what verifications and information remained due. The CWA's
December 2016 revised notice of denial, with the correct date of the deposit,
removed any doubt – which could not have existed – because it re-explained the
basis for the denial. Thus, her argument is without merit.
Finally, the documentary evidence and testimony from the Medical
Coordinator for the nursing home and the CWA's caseworker show that the
CWA gave R.A. sufficient notice of what it required while the application was
pending. These witnesses testified after the ALJ administered the oath to tell
the truth. Thus, they were sworn in. The caseworker testified that she had not
received a copy of the settlement check, verification of how the proceeds were
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spent, or an appraisal for the property. The Medical Coordinator admitted that
she had not provided the requested verifications to support the application.
Therefore, even without the testimony from the CWA's Fair Hearing Liaison –
the individual who R.A. claims was not sworn in – there existed sufficient
evidence in the record to support the ALJ's findings.
Applying the governing standards of review and legal principles, we
conclude there exists substantial credible evidence in the record to support the
Director's findings, and that the final agency decision was not arbitrary,
capricious, or unreasonable.
Affirmed.
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