P.N. VS. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES (DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES)

• Court: New Jersey Superior Court Appellate Division
• Decided: July 28, 2017
• Docket: A-2025-15T2
• Status: Unpublished

Opinion

NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION This opinion shall not "constitute precedent or be binding upon any court."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-2025-15T2

P.N.,

Petitioner-Appellant,

v.

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES and UNION COUNTY BOARD OF SOCIAL SERVICES,

Respondents-Respondents. _____________________________________

Submitted July 18, 2017 – Decided July 28, 2017

Before Judges Reisner and Suter.

On appeal from the Division of Medical Assistance and Health Services, Department of Human Services.

Thomas M. Wolfe, attorney for appellant.

Christopher S. Porrino, Attorney General, attorney for respondent Division of Medical Assistance and Health Services (Melissa H. Raksa, Assistant Attorney General, of counsel; Melissa Bayly, Deputy Attorney General, on the brief).

PER CURIAM P.N. appeals the November 17, 2015 final agency decision of

the Division of Medical Assistance and Health Services (DMAHS)

that denied her application for Medicaid benefits. We affirm.

In October 2013, a paralegal in the office of P.N.'s attorney

called the Union County Welfare Board (CWB) to request information

about Medicaid for P.N., and testified she was told a letter would

be sent to her scheduling an appointment. P.N. was physically

eligible for Medicaid, based upon an earlier pre-administrative

screening. She resided in an assisted-living facility.

When P.N.'s attorney did not receive an appointment or a

denial letter, in March 2014, he sent a letter to a supervisor at

CWB advising that P.N. needed to apply for Medicaid. The letter

requested "an appointment to present this Medicaid application."

CWB responded two months later, advising P.N. to attend an

appointment on June 13, 2014, and to bring with her various

financial documents.

P.N.'s application for Medicaid was submitted on June 13,

2014, but she did not thereafter provide all the information

required to determine her eligibility. On November 7, 2014, P.N.'s

counsel was advised that P.N.'s application would be denied unless

information needed to verify her income was provided by November

21, 2014. On November 26, 2014, P.N's application for Medicaid

was denied because she had not provided "numerous bank statements,

2 A-2025-15T2 bills and other documentation. [She] only provided a part of the

information requested. [Her] application [was] denied for failing

to provide the necessary verifications to process [the case]."

At P.N.'s request, a hearing was conducted concerning the

denial of her application. On October 7, 2015, the Administrative

Law Judge's initial decision affirmed the denial of Medicaid

benefits to P.N., finding she was "not eligible for Medicaid

because she failed to provide the requested verifications, and

even if she had, her resources . . . exceeded the limit at the

operative times." The November 17, 2015 final agency decision

upheld the denial of benefits as appropriate because P.N's June

2014 application for Medicaid did not provide the needed

information to determine eligibility before the November 26, 2014

denial.

On appeal, P.N. contends DMAHS's final agency decision was

arbitrary and capricious by failing to examine all the facts, and

further, that DMAHS should be estopped from denying the application

retroactively to October 2013.

We review an agency's decision for the limited purpose of

determining whether its action was arbitrary, capricious or

unreasonable. "An administrative agency's decision will be upheld

'unless there is a clear showing that it is arbitrary, capricious,

or unreasonable, or that it lacks fair support in the record.'"

3 A-2025-15T2 R.S. v. Div of Med. Ass't and Health Servs., 434 N.J. Super. 250,

261 (App. Div. 2014) (quoting Russo v. Bd. of Trs., Police &

Firemen's Ret. Sys., 206 N.J. 14, 25 (2011)). "The burden of

demonstrating that the agency's action was arbitrary, capricious

or unreasonable rests upon the [party] challenging the

administrative action." E.S. v. Div. of Med. Assistance & Health

Servs., 412 N.J. Super. 340, 349 (App. Div. 2010) (alteration in

original) (quoting In re Arenas, 385 N.J. Super. 440, 443-44 (App.

Div.), certif. denied, 188 N.J. 219 (2006)).

"Medicaid is a federally-created, state-implemented program

that provides 'medical assistance to the poor at the expense of

the public.'" Matter of Estate of Brown, 448 N.J. Super. 252, 256

(App Div.) (quoting Estate of DeMartino v. Div. of Med. Assistance

& Health Servs., 373 N.J. Super. 210, 217 (App. Div. 2004), certif.

denied, 182 N.J. 425 (2005); 42 U.S.C.A. § 1396-1), certif. denied,

__ N.J. __ (2017). To receive federal funding, the State must

comply with all the federal statutes and regulations. Harris v.

McRae, 448 U.S. 297, 301, 100 S. Ct. 2671, 2680, 65 L. Ed. 2d 784,

794 (1980).

In New Jersey, the Medicaid program is administered by DMAHS

pursuant to the New Jersey Medical Assistance and Health Services

Act, N.J.S.A. 30:4D-1 to -19.5. The county welfare boards evaluate

eligibility. "In order to be financially eligible, the applicant

4 A-2025-15T2 must meet both income and resource standards." Brown, supra, 448

N.J. Super. at 257 (citing N.J.A.C. 10:71-3.15).

Under DMAHS's regulations, it establishes "policy and

procedures for the application process." N.J.A.C. 10:71-2.2(b).

The county welfare boards exercise direct responsibility in the

application process to . . . receive applications." Id. at 2.2(c).

They also "[a]ssure the prompt and accurate submission of

eligibility data." Id. at 2.2(c)(5). The regulations establish

time frames to process an application, with the "date of effective

disposition" being the "effective date of the application" where

the application has been approved. N.J.A.C. 10:71-2.3(b)(1).

DMAHS's final agency decision was not arbitrary, capricious

or unreasonable. P.N. did not dispute that her written application

for Medicaid was submitted in June 2014, or that information was

missing to determine her eligibility for benefits. When the

verifying information was not provided, DMAHS properly denied the

application. P.N. provides no authority for her contention that

the phone call in October 2013 could substitute for a formal

application consistent with DMAHS's regulations.1 Moreover, DMAHS

1 To the extent P.N. may have "outstanding unpaid medical bills incurred within the three month period prior to the month of application for Medicaid Only," the regulations provide a procedure for making application for retroactive eligibility for Medicaid, see N.J.A.C. 10:71-2.16, but the triggering date is the "month of application," not a phone call.

5 A-2025-15T2 was correct to deny an application that did not have the

information necessary to verify eligibility because Medicaid is

intended to be a resource of last resort and is reserved for those

who have a financial or medical need for assistance. See N.E. v.

Div. of Med. Assistance & Health Servs., 399 N.J. Super. 566, 572

(App. Div. 2008).

After carefully reviewing the record and the applicable legal

principles, we conclude that P.N.'s further arguments are without

sufficient merit to warrant discussion in a written opinion. R.

2:11-3(e)(1)(E).

Affirmed.

6 A-2025-15T2