loading…
loading…
loading…
Page 8 of 12 § 10:71-2.3 Policy and procedure on prompt disposition and mental and emotional status during the application period rendered her incapable of assisting DMAHS and providing the necessary documents. Those conditions constituted "exceptional circumstances" within the meaning of relevant regulations that warranted an extension of time to provide the documents. The ALJ noted in so finding that the purpose of the regulatory scheme was to facilitate disposition of a Medicaid application on the merits. So long as there was good reason for a failure to provide all documentation, the better practice would be to extend the deadline, obtain all relevant information, and make a determination of the merits. J.F. v. DMAHS and Cumberland Cty. Bd. of Social Servs., OAL DKT. NO. HMA 9678-14 and HMA 17109-14 (CONSOLIDATED), 2015 N.J. AGEN LEXIS 189, Initial Decision (March 6, 2015). Determination by a county board of social services (BSS) denying an application for Medicaid eligibility filed by a nursing home on behalf of a resident therein was not supported by the record because the evidence showed that the resident's condition was such that she could not assist the home in collecting the bank statements that the BSS had requested and the home had made substantial efforts to gather and provide the information requested. Though agreeing that all of the documentation had not been provided, the administrative law judge (ALJ) found that given the resident's inability to assist in assembling the materials and the efforts made to date by the home, denial of eligibility at this time was not appropriate and the home should be afforded additional time within which to try and gather the remaining materials. S.H. v. Essex Cty. Bd. of Social Servs., OAL DKT. NO. HMA 16991-14, 2015 N.J. AGEN LEXIS 188, Initial Decision (March 6, 2015). Determination by a county Board of Social Services (CBSS) denying Medicaid benefits to an applicant on the ground that the applicant had failed to provide required verification and had failed to assist the CBSS in securing relevant documentation was rejected by an administrative law judge. The applicant was a 71 year old who suffered from both psychiatric and physical conditions, and his application had been filed by his estranged wife, from whom he had been separated for 10 years. The testimonial and documentary evidence in the record supported the wife's position that she had responded to the best of her ability to the requests made by the caseworker and was attempting to cooperate with the agency to the extent that she could. A fair reading of the governing regulations showed that there were circumstances where the processing of an application would be delayed beyond the time that was normally essential and that the circumstances of this case were such that the agency should have afforded more time to the wife to address documentation requests made by the caseworker. On that basis, the application was properly reinstated. R.C. v. Camden Cty. Bd. of Social Servs., OAL DKT. NO. HMA 13064-2014, 2015 N.J. AGEN LEXIS 205, Initial Decision (February 12, 2015). Determination by a county Board of Social Services (CBSS) denying Medicaid benefits to an applicant on the ground that the applicant had failed to provide required information was rejected by an Administrative Law Judge (ALJ) on findings that the agency had ignored applicable regulations. Because the applicant had Alzheimer's and was confined to a nursing home, she was unable to assist her daughters, who filed the application on her behalf. To the extent that the application was denied on the ground that the daughters had not cooperated, the record did not support that position because that provision concerns cases where an applicant or her representative did not cooperate. Here, the daughters clearly were cooperating to the best of their ability. Moreover, there could be a basis for concluding that the failure to obtain verification of a single item in the amount of $ 45.88 was the fault of the agency, which might have had more success in dealing with the insurance company that had issued it. Finally, though there was authority for the agency's proposition that the normal deadline for compliance had passed, the regulation also recognized that there were circumstances where the processing of an application would be delayed beyond the time that was normally utilized and the agency should have allowed additional time. On that basis, the matter was properly remanded to the agency for a disposition on the merits. M.D. v. DMAHS and Atlantic Cty. Bd. of Social Servs., OAL DKT. NO. HMA 14997-14, 2015 N.J. AGEN LEXIS 210, Initial Decision (February 10, 2015). Division of Medical Assistance and Health Services and Cape May County Board of Social Services (agency) improperly denied an application for Medicaid benefits for failure to timely provide documentation under N.J.A.C. 10:71-2.3(a). The purpose of that regulation is not to fix a deadline for an applicant to produce documents, but rather to set a deadline for the agency to process the application. It was the agency, not the applicant, that delayed action for large periods of time, and then, after demanding a veritable mountain of additional documents, the agency summarily denied the application 32 days after the final request letter. In addition, the inability of the