DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES, et al. v. K.H.

 

NOT FOR PUBLICATION WITHOUT THE

APPROVAL OF THE APPELLATE DIVISION

SUPERIOR COURT OF NEW JERSEY

APPELLATE DIVISION

DOCKET NO. A-4940-04T2 4940-04T2

DIVISION OF MEDICAL

ASSISTANCE AND HEALTH

SERVICES,

Petitioner-Respondent,

and

OCEAN COUNTY

BOARD OF SOCIAL SERVICES,

Petitioner,

v.

K.H.,

Respondent-Appellant.

 

Submitted December 7, 2005 - Decided

Before Judges Conley and Winkelstein.

On appeal from a final decision of the Department of Human Services, Division of Medical Assistance and Health Services, HMA-8811-02.

John W. Callinan, attorney for appellant.

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

PER CURIAM

K.H., an eighty-five-year-old woman, challenges a June 11, 2003 determination of the Division of Medical Assistance and Health Services (the Agency) that reversed an Administrative Law Judge's (ALJ) decision to award her Medicaid benefits and transfer her case from Ocean County to Monmouth County. The Agency remanded the matter to the Office of Administrative Law (OAL) "for proceedings on K.H.'s termination of benefits by Ocean County." K.H. also appeals from the Agency decision following the remand, dated April 15, 2005, that terminated her Medicaid benefits as a result of her failure to timely verify her resources and the status of her late husband's estate. We affirm.

The material facts and procedural history are substantially undisputed. K.H., who lived with her husband J.H. in Ocean County, was hospitalized and placed in the Jersey Shore Center in Eatontown, Monmouth County, in September 2001. The Ocean County Board of Social Services (Ocean County) awarded K.H. Medicaid effective October 1, 2001.

On November 15, 2001, her husband died testate; in his will, he devised to K.H. "so much of the residue of my estate as is required to satisfy my spouse's right to an elective share of my estate, pursuant to N.J.S.A. 3B:8-1 et seq." The trustee was empowered to apply income, as well as so much of the principal as was necessary, to maintain K.H.'s health, safety and welfare.

Following J.H.'s death, Ocean County determined that because K.H. had resources available from the estate, she was ineligible for Medicaid; consequently, the County terminated her Medicaid benefits effective December 30, 2001. On June 19, 2002, the Agency determined that Ocean County had prematurely terminated K.H.'s Medicaid benefits; nevertheless, it also found "[t]hat nothing in this Final Agency Decision shall preclude or prevent Ocean County from taking action against K.H. upon settlement of the estate."

By letter of July 10, 2002, Ocean County informed K.H.'s attorney that it was preparing to reinstate K.H.'s Medicaid retroactive to January 1, 2002, but it first needed to determine her eligibility. The County asked for information regarding her income from the estate and elsewhere. When not all of the requested information was supplied, by letter of September 9, 2002, Ocean County again requested the information; among other things, it asked for the disposition of a number of J.H.'s assets and the status of his estate. When K. H. did not provide the requested information, Ocean County sent a follow-up letter on October 24, 2002, again requesting the information; the letter said that "failure to respond will result in termination of benefits effective 11/30/02."

By letter of November 4, 2002, K.H.'s attorney told Ocean County to direct all communications to him, and, because K.H. had not been a resident of Ocean County since October 2001, to transfer the case to Monmouth County. By letter of November 12, 2002, Ocean County declined to make the transfer. It again requested the information, and informed K.H. that because it had not been provided with information concerning K.H.'s "available resources and the disposition of [J.H.'s] estate, . . . unless you send the verification requested by November 19, 2002, we will have no choice other than to terminate [K.H.'s] Medicaid case as of November 30, 2002."

On November 20, 2002, not having received the requested information, Ocean County notified K.H. that her benefits would be terminated effective the end of the month as a result of the failure to verify resources. By letter dated November 25, 2002, and received by Ocean County the following day, K.H.'s attorney supplied the previously-requested information.

When K.H. challenged the decision to terminate her benefits, the case was transmitted as a contested case to the OAL, where a hearing was held on April 8, 2003. In a decision dated April 25, 2003, the ALJ ordered Ocean County to transfer responsibility for K.H.'s case to the Monmouth County Board of Social Services (Monmouth County); the judge also vacated Ocean County's termination of K.H.'s benefits.

On June 11, 2003, the Agency reversed the ALJ. It remanded the case to the OAL for a hearing limited to the termination notice issued by Ocean County. The Agency found that "many questions have come up regarding K.H.'s eligibility such that the sending county, Ocean, would not be able to transfer the case as an eligible beneficiary."

On remand, the case went to a different ALJ. He heard the case de novo on June 1, 2004. On January 18, 2005, he found, in part:

K.H., through her legal representatives, did not cooperate fully with the [Ocean County] verification process. Neither K.H.'s agent nor her attorney timely responded to the September 9 and October 24 letters from [Ocean County]. The requested information was not delivered to [Ocean County] until after the agency decided to terminate K.H.'s Medicaid case and issued the termination notice on November 20.

Accordingly, the ALJ determined that Ocean County properly terminated K.H.'s Medicaid benefits because J.H.'s testamentary trust was countable as a resource to K.H., which disqualified her for Medicaid. On April 15, 2005, the Agency adopted the ALJ's recommendation that K.H.'s benefits should be terminated effective November 30, 2002.

Subsequently, K.H. transferred her assets, and her nursing home applied to Monmouth County for Medicaid benefits on her behalf. Her eligibility for Medicaid benefits became effective April 1, 2005, following the expiration of a period of ineligibility.

It is not the decision of the ALJ that comes before us on appeal; rather, the appeal is from final decisions of State administrative agencies. R. 2:2-3(a)(2); Newman v. Ramapo Coll. of N.J., 349 N.J. Super. 196, 201 (App. Div. 2002); In re Silberman, 169 N.J. Super. 243, 255-56 (App. Div. 1979), aff'd, 84 N.J. 303 (1980). Our standard of review of an agency's decision is well settled. We will not upset the determination unless it was arbitrary, capricious or unreasonable, or not supported by substantial evidence in the record as a whole. In re Taylor, 158 N.J. 644, 656-57 (1999); Campbell v. Dep't of Civil Serv., 39 N.J. 556, 562 (1963). Applying this standard, we do not find either the Agency's June 11, 2003 rejection of the ALJ's decision, and its remand for a de novo hearing, or its April 15, 2005 decision upholding the ALJ's recommendation to terminate K.H.'s Medicaid benefits, to have been arbitrary, capricious or unreasonable.

The June 11, 2003 decision reversed: (1) the ALJ's award of Medicaid benefits to K.H. and (2) his transfer of the case to Monmouth County. The Agency reasoned that it was up to Ocean County to make the initial determination of eligibility before transferring the case to Monmouth County. Questions of K.H.'s cooperation and eligibility for Medicaid remained unanswered. The Agency wanted those questions resolved before an award of benefits could be made, and it wanted Ocean County to resolve them. The Agency Director found: "to transfer the case after a year has elapsed and require Monmouth County to duplicate the review already undertaken by Ocean County would unnecessarily squander public funds." We find nothing unreasonable or arbitrary about that decision.

Nor do we find the April 15, 2005 decision to have been arbitrary or unsupported in the record. The ALJ held a de novo hearing and, based on substantially uncontroverted facts, concluded that K.H., through her attorney and agents, failed to timely provide the requested documentation regarding her investments and resources. Ocean County had initially asked for that information in its July 10, 2002 letter to K.H.'s attorney; and followed-up with additional requests over the next several months. Yet, it was not until November 26, 2002, six days past the November 19 cut-off date, that Ocean County received the requested information. On these facts, the Agency's decision to terminate benefits was not unreasonable. It is not for us to substitute our judgment for that of the Agency.

 
Affirmed.

(continued)

(continued)

3

A-4940-04T2

RECORD IMPOUNDED

December 16, 2005