IN THE MATTER ELIGIBILITY OF R.V. FOR MEDICALLY NEEDY PROGRAM MEDICAID BENEFITS.

 

NOT FOR PUBLICATION WITHOUT THE

APPROVAL OF THE APPELLATE DIVISION

SUPERIOR COURT OF NEW JERSEY

APPELLATE DIVISION

DOCKET NO. A-5949-04T25949-04T2

IN THE MATTER OF THE ELIGIBILITY

OF R.V. FOR MEDICALLY NEEDY

PROGRAM MEDICAID BENEFITS.

 

Submitted: May 1, 2006 - Decided July 19, 2006

Before Judges Fall and Yannotti.

On appeal from the final administrative decision of the Department of Human Services, Division of Medical Assistance and Health Services, Case Number 1315001093.

Albert J. Rescinio, attorney for appellant R.V.

Zulima V. Farber, Attorney General, attorney for respondent (Michael J. Haas, Assistant Attorney General, of counsel; Dianna Rosenheim, Deputy Attorney General, on the brief).

PER CURIAM

R.V., by his son and guardian E.V., appeals from a final administrative decision issued by the Division of Medical Assistance and Health Services (DMAHS) of the Department of Human Services on June 13, 2005, denying as untimely his request for a fair hearing concerning the termination of R.V.'s eligibility for Medically Needy Program Medicaid benefits on the basis that his resources had exceeded the $4,000 limit prescribed by N.J.A.C. 10:70-5.1(a). The following factual and procedural history is relevant to our consideration of the arguments advanced on appeal.

E.V. is the only son of R.V. and J.V. E.V. suffers from life-long disabilities. In 1993, R.V. was diagnosed with Huntington's Disease. On July 15, 1999, R.V. executed a power of attorney, giving E.V. the power to manage all of his affairs. On July 31, 1999, R.V. entered a nursing home.

In March 2000, J.V. executed a will that left all of her assets to E.V., but created a supplemental benefits trust for the benefit of R.V. That trust was funded by the amount of R.V.'s elective surviving-spouse share of her estate. See N.J.S.A. 3B:8-1. E.V. was named trustee of the trust and executor of J.V.'s estate.

J.V. died on February 13, 2003, leaving a gross estate of $515,855, and a net estate of $500,855. In or about April 2003, the supplemental benefits trust was funded with $110,000. R.V.'s elective share of his wife's estate was $166,935; from that amount, a check in the amount of $58,065.40 was issued to the State of New Jersey to reimburse the State for all Medicaid benefits paid from May 1, 2000 to February 1, 2003.

R.V. had been receiving benefits from the Medically Needy Program, which provides benefits to recipients who have a higher income than other Medicaid recipients. See N.J.A.C. 10:70-1.1 to -7.3. By letter addressed to E.V. dated December 3, 2004, citing to N.J.A.C. 10:71-4.5(c), the Monmouth County Board of Social Services terminated the Medicaid eligibility of R.V., effective October 31, 2003, on the basis that R.V.'s resources had exceeded the $4,000 eligibility limit. The notice attached information advising that the recipient had the right to request a "Fair Hearing" within twenty (20) days of the date of the letter.

By letter to the Division dated June 8, 2005, counsel for R.V. enclosed a Fair Hearing Request, contending that the December 3, 2004 determination by the Monmouth County Board of Social Services was erroneous, and requested benefits be re-established retroactively to October 31, 2003. By letter to R.V.'s counsel dated June 13, 2005, DMAHS stated in pertinent part:

Please be advised that your request for a hearing in the above-referenced matter is denied because it was received on June 10, 2005 which is beyond 20 days from the December 3, 2004 date of the denial notice.

You may appeal this decision by contacting the Clerk, Appellate Division, Superior Court of New Jersey, Richard J. Hughes Justice Complex, CN-006, Trenton NJ 08625. Please note that a request for judicial review of this Decision must be filed with the Clerk within 45 days from the date of your receipt of this letter.

R.V. filed a notice of appeal from that decision on July 14, 2005. On appeal, the appellant presents the following argument for our consideration:

POINT I

THE NOTICE OF TERMINATION OF MEDICAID BENEFITS FROM THE MONMOUTH COUNTY DIVISION OF SOCIAL SERVICES WAS DEFICIENT IN SEVERAL ASPECTS AND WITH THE DENIAL OF THE FAIR HEARING REQUEST, THE APPELLATE DIVISION BECOMES THE FORUM TO HEAR THE CASE ON ITS MERITS.

Appellant argues that his guardian E.V. "suffers from life long learning disabilities[]" that "prevented [him] from being able to fully comprehend and understand the issues in the December 3, 2004, correspondence[.]" R.V. also asserts that he was never noticed, as recipient, by DMAHS of the termination of his Medicaid benefits. R.V. further contends that the December 3, 2004 notice failed to contain a full explanation of the reason for the termination of his benefits nor the actual calculations used in arriving at that determination.

"Medicaid is a federal program that provides funds to states so that eligible needy persons may be reimbursed for the cost of medical care. 42 U.S.C.A. 1396a to -1396v; Mistrick v. Division of Med. Assistance and Health Servs., 154 N.J. 158, 165 (1998). The states have significant discretion to design programs, but those programs must be consistent with federal law. . . . In New Jersey, the implementing statutory provisions are set forth in the Medical Assistance and Health Services Act, N.J.S.A. 30:4D-1 to -42." A.K. v. Division of Med. Assistance, 350 N.J. Super. 175, 178-79 (App. Div. 2002) (other citations omitted).

When an individual's benefits under the Medically Needy Program are terminated, due process requires that the recipient receive written notice from the county welfare agency stating the nature of the agency decision and an accurate factual and legal basis for the decision, as well as an explanation of the right to a fair hearing. See N.J.A.C. 10:70-7.1; see also N.J.A.C. 10:49-10.1 to -10.13 (specifying the procedures for appeals and fair hearings).

After analyzing the record and the written arguments advanced by the parties, we conclude that there is inadequate support for the determination by DMAHS denying R.V. a fair hearing. Although the December 3, 2004 notice was addressed to E.V., there is no indication that R.V., the actual recipient of Medicaid benefits, was notified. Moreover, the notice itself cited the wrong regulation as the basis for ineligibility, failed to specify the actual factual basis for the determination, and failed to include the actual calculation used by the agency to arrive at its determination. See Meyer v. Department of Human Servs., 269 N.J. Super. 310, 312 (App. Div. 1993) (notice informing claimant that his food stamp benefits eligibility would be reduced because of an increase in his SSI benefit was insufficient in that it failed to inform claimant of the method by which the reduction in his benefits had been calculated). See also Ortiz v. Eichler, 616 F. Supp. 1046, 1061-62 (D. Del. 1985) (due process notice requires that where calculations of a claimant's resources are involved, the agency must set forth those calculations to adequately explain how it arrived at its decision), aff'd, 794 F.2d 889 (3d Cir. 1986); In re Fair Hearing Decision, 138 N.J. Super. 417, 424 (App. Div. 1976) (noting that rules "relating to the time of filing of claims should be construed as directory in nature so as to avoid an injustice where the facts demand it"). Additionally, there is a substantial question raised as to the ability of E.V. the person who received the notice to perceive or understand the content of the notice and its consequences.

Accordingly, we reverse the June 13, 2005 decision of DMAHS denying appellant a fair hearing, and remand the matter for the agency to conduct a fair hearing on its determination to deny R.V. further Medically Needy Program Medicaid benefits. We express no opinion on the merits of R.V.'s appeal, and are mindful of our recent decision in I.G. v. Department of Human Servs., ___ N.J. Super. ___ (App. Div. 2006) (slip op. at 2) (holding that failure of Medicaid recipient to elect marital share of husband's estate constituted a transfer of available resources rendering her ineligible for Medicaid).

Reversed and remanded.

 

These are the approximate values of J.V.'s estate, as contained in appellant's brief.

Presumably, one of the issues that would have been reached had there been a determination on the merits was whether these trust funds provisions constituted an excludable resource pursuant to N.J.A.C. 10:71-4.4(b)6i.

The resources limit of $4,000 for eligibility for the Medically Needy Program is prescribed in N.J.A.C. 10:70-5.1(a), not the regulation cited in the December 3, 2004 letter.

(continued)

(continued)

7

A-5949-04T2

RECORD IMPOUNDED

July 19, 2006