Hk v. Dmahs

878 A.2d 16, 379 N.J. Super. 321
CourtNew Jersey Superior Court Appellate Division
DecidedJuly 29, 2005
StatusPublished

This text of 878 A.2d 16 (Hk v. Dmahs) is published on Counsel Stack Legal Research, covering New Jersey Superior Court Appellate Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hk v. Dmahs, 878 A.2d 16, 379 N.J. Super. 321 (N.J. Ct. App. 2005).

Opinion

878 A.2d 16 (2005)
379 N.J. Super. 321

H.K., Petitioner-Appellant,
v.
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES and Cape May County Board of Social Services, Respondents-Respondents.

Superior Court of New Jersey, Appellate Division.

Submitted June 1, 2005.
Decided July 29, 2005.

Nancy M. Rice, Haddonfield, attorney for appellant (Ms. Rice, Grayson H. Heberley *17 and Tina DiDomenico Angeloni, on the brief).

Peter C. Harvey, Attorney General, attorney for respondent (Michael J. Haas, Assistant Attorney General, of counsel; Caitlin L. Aviss, Deputy Attorney General, on the brief).

Before Judges WECKER, S.L. REISNER and SELTZER.

The opinion of the court was delivered by

S.L. REISNER, J.A.D.

This case concerns the continuing tension between the State's effort to conserve Medicaid resources for the truly needy and the legal ability of institutionalized Medicaid recipients to shelter income for the benefit of their non-institutionalized spouses. In this case, we hold that the applicant and his wife transgressed the permissible limits of Medicaid planning by entering into a divorce from bed and board[1] and agreeing, in a consent order entered without judicial fact finding, that the institutionalized husband's pension benefits would be paid to the wife as alimony.

I

The facts in this case were largely stipulated. The husband, H.K., suffered a debilitating stroke and was admitted to a nursing home in May 2002. H.K. initially applied for Medicaid, under the "medically needy" nursing home program, in May 2002, but could not qualify until he and his wife, R.K., had "spent down" their available resources to the limit that would qualify H.K. for Medicaid. See N.J.A.C. 10:71-4.8; H.K. v. Div. of Med. Assistance & Health Servs., 184 N.J. 367, 380-82, 877 A.2d 1218, 1226-27 (2005); Estate of F.K. v. Div. Med. Assistance & Health Servs., 374 N.J.Super. 126, 134-35, 863 A.2d1065 (App.Div.), certif. denied, 184 N.J. 209, 876 A.2d 283 (2005). They reached that limit in August of 2002.

H.K. was able to qualify for medically needy nursing home Medicaid even though he had Social Security and pension income of approximately $4,500 per month and his wife worked full-time and earned over $2,000 per month. However, H.K. was required to use his pension and Social Security benefits to pay part of the cost of his nursing home care. See N.J.A.C. 10:70-4.1 and -6.1. Medicaid would pay for the balance of the nursing home costs. See L.M. v. Div. of Med. Assistance & Health Servs., 140 N.J. 480, 486-88, 659 A.2d 450 (1995).[2]

The Federal Medicaid statute, 42 U.S.C.A. § 1396r-5(d), and our State's implementing regulations, N.J.A.C. 10:71-5.7(c), recognize that some portion of an institutionalized spouse's income may be used to support the community spouse to avoid the latter from becoming impoverished. *18 See Wisconsin Dep't of Health and Family Servs. v. Blumer, 534 U.S. 473, 480, 122 S.Ct. 962, 968, 151 L.Ed.2d 935 (2002) ("Congress sought to protect community spouses from `pauperization' while preventing financially secure couples from obtaining Medicaid assistance."). But those same provisions place strict limits on the amount of a Medicaid recipient's income that can be used for the community spouse allowance. Id. at 481-82, 122 S.Ct. at 965. At the time H.K. qualified for Medicaid, the spousal allowance was normally limited to $1,493. See N.J.A.C. 10:71-5.7(c); Division of Medical Assistance and Health Services Medicaid Communication No. 02-17 (July 5, 2002). A community spouse may obtain a larger allowance by demonstrating, at an administrative hearing, that he or she suffers "exceptional circumstances resulting in financial duress." N.J.A.C. 10:71-5.7(e). See 42 U.S.C.A. § 1396r-5(e). A separate provision, N.J.A.C. 10:71-5.7(f), permits an alternative means of obtaining support for the community spouse:

If a court has entered an order against an institutionalized spouse for monthly income for the support of a community spouse and the amount of the order is greater than the amount of the community spouse deduction, the amount so ordered shall be used in place of the community spouse deduction.

This regulation implements an analogous provision in the federal Medicaid statute, 42 U.S.C.A. § 1396r-5(d)(5).[3]

R.K.'s monthly income was too high to entitle her to a community spousal allowance under N.J.A.C. 10:71-5.7(c). Therefore, unless R.K. qualified for an exception to the cap set by section 5.7(c), H.K.'s entire income would be used to pay for his nursing home care.

H.K. and R.K. attempted to invoke the "court order" exception of N.J.A.C. 10:71-5.7(f), by obtaining a divorce from "bed and board" with a property settlement agreement providing for support to be paid to R.K. from H.K.'s pension.[4] The divorce action was filed in October 2002 and was finalized by consent on December 24, 2002. The Final Judgment of Divorce From Bed and Board specifically recited that the property settlement agreement, incorporated in the judgment, was entered without the court having taken testimony "as to the merits thereof, and therefore [the court] makes no judgment with respect to the fairness thereof." Based on this final judgment, H.K. sought recalculation of H.K.'s Medicaid benefit, claiming that the court order for her support superceded the cap on the spousal *19 allowance. But on March 20, 2003, the Board declined to recognize H.K.'s support obligation to R.K. as a deduction for Medicaid purposes.

H.K. appealed that determination at a hearing before the Office of Administrative Law (OAL), claiming that N.J.A.C. 10:71-5.7(f) required the Board to recognize and include his court-ordered spousal support obligation in calculating his income for Medicaid purposes.

Administrative Law Judge Todd Miller rejected H.K.'s contention in an initial decision on February 10, 2004. He reasoned that a literal reading of the regulation would lead to an absurd result, allowing Medicaid applicants to transfer additional income to their spouses without a showing of exceptional circumstances and financial duress, which the Medicaid statute and regulations would otherwise require. 42 U.S.C.A. § 1396r-5(e)(2)(B); see N.J.A.C. 10:71-5.7(e). He concluded that "the evidence in this case did not involve financial duress or exceptional circumstances. Rather, it came about through crafty planning by combining an old divorce statute with a regulation intended to offer relief to those in financial need. . . . [A] substitute maintenance deduction is not presently necessary to alleviate financial duress."

The State Division of Medical Assistance and Health Services (DMAHS) adopted the Initial Decision in a final determination dated May 17, 2004. The DMAHS decision reasoned that giving effect to the divorce judgment "would be contrary to the purpose and intent of the Medicare Catastrophic Coverage Act" which was intended to avoid pauperization of the community spouse by assuring that she would be allowed "sufficient" but "not excessive" income.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

DiMaria v. Bd. of Tr. of PERS
542 A.2d 498 (New Jersey Superior Court App Division, 1988)
Weinkrantz v. Weinkrantz
322 A.2d 184 (New Jersey Superior Court App Division, 1974)
LM v. State, Div. of Med. Assist. & Health Serv.
659 A.2d 450 (Supreme Court of New Jersey, 1995)
Simpkins v. Saiani
811 A.2d 474 (New Jersey Superior Court App Division, 2002)
Paper Mill Playhouse v. Millburn Township
472 A.2d 517 (Supreme Court of New Jersey, 1984)
Estate of G.E. v. Division of Medical Assistance & Health Services
638 A.2d 833 (New Jersey Superior Court App Division, 1994)
H.K. v. Division of Medical Assistance & Health Services
878 A.2d 16 (New Jersey Superior Court App Division, 2005)
H.K. v. State
877 A.2d 1218 (Supreme Court of New Jersey, 2005)

Cite This Page — Counsel Stack

Bluebook (online)
878 A.2d 16, 379 N.J. Super. 321, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hk-v-dmahs-njsuperctappdiv-2005.