Court Opinion

ID: 5126639
Source: CourtListenerOpinion
Date Created: 2021-11-17 16:10:05.662549+00
Date Added: 2024-06-11T08:20:18.659069
License: Public Domain

NOT FOR PUBLICATION WITHOUT THE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-1337-19

C.M.,

          Petitioner-Appellant,

v.

SUSSEX COUNTY BOARD
OF SOCIAL SERVICES,

     Respondent-Respondent.
__________________________

                   Submitted October 25, 2021 – Decided November 17, 2021

                   Before Judges Messano and Enright.

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

                   C.M., appellant pro se.

                   Andrew J. Bruck, Acting Attorney General, attorney for
                   respondent Division of Medical Assistance and Health
                   Services (Melissa H. Raksa, Assistant Attorney
                   General, of counsel; Jacqueline R. D'Alessandro,
                   Deputy Attorney General, on the brief).
            Hollander, Strelzik, Pasculli, Hinkes, Vandenberg,
            Hontz & Olenick, LLC, attorneys for respondent
            Sussex County Board of Social Services (Michelle L.
            Olenick, on the brief).

PER CURIAM

      Petitioner C.M. 1 appeals from the October 28, 2019, final agency decision

of the Division of Medical Assistance and Health Services (DMAHS)

terminating her household's Medicaid benefits. We reverse and remand.

      The calculation of C.M.'s household income for 2019 forms the basis for

the instant appeal. When this matter commenced, C.M. lived in Sussex County,

New Jersey with her husband, J.L.M., and their four tax-dependent children. In

2018, C.M.'s family was financially eligible for New Jersey FamilyCare (NJFC)

Medicaid benefits based on the household's income for the 2017 tax year. But

in December 2018, the Sussex County Board of Social Services (the County

Welfare Agency, or CWA) discovered C.M.'s earnings were $3,917.26 per

month, that her husband's business losses equated to $1,217.50 per month, and

that her son, J.M., had earnings from his employment at ShopRite averaging

$1,348.91 per month (J.M. had started his part-time job with ShopRite in May

2018). Thus, the CWA calculated petitioner's projected household income for

1
  We use initials to protect the privacy interests of petitioner and her family
members.
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                                       2
2019 to be $4,048.67 per month, which exceeded the Modified Adjusted Gross

Income (MAGI) limit of $3,881 per month for the household.2 Accordingly, by

letter dated December 27, 2018, the CWA informed C.M. that her Medicaid

benefits, as well as those of her husband and their three older children, would

be terminated on January 31, 2019, and her youngest child's benefits would end

on March 31, 2019.

      C.M. appealed the termination, and her request was transmitted to the

Office of Administrative Law (OAL). The ALJ conducted a fair hearing on

February 25, 2019, and on March 4, 2019, she issued an initial decision

reversing the termination. Noting J.M. was a college student, the ALJ concluded

it could not "be assumed at this point" that J.M. would continue to work at

ShopRite consistently throughout 2019 so that he would be required to file a

2019 tax return.

      In May 2019, DMAHS rejected the ALJ's initial decision and affirmed the

termination of benefits for C.M.'s household. DMAHS found the CWA properly

2
  This MAGI limit is reflected in the merits briefs of C.M. and the CWA, as
well as the March 4, and September 3, 2019 opinions of Administrative Law
Judges (ALJs) respectively; respondent DMAHS asserts the MAGI limit for
2019 was $3,978. It is unnecessary for us to resolve the conflicting figures,
because as of December 2018, C.M.'s projected household income for 2019
exceeded both amounts.
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                                      3
considered J.M.'s prospective income as of December 2018 when assessing the

family's household income, and that the CWA appropriately informed C.M. her

household Medicaid benefits would terminate based on its projection C.M.'s

household income would exceed the MAGI threshold.

      In June 2019, C.M. sought emergent relief before us. We determined there

were "factual disputes regarding whether [J.M.] will continue to work similar

hours throughout the 2019 tax year, whether he will be required to file a tax

return for the 2019 tax year, and whether his projected average monthly income

would disqualify the family from Medicaid/[NJFC] Program benefits."

Therefore, we stayed the termination of benefits and on June 6, 2019, we

remanded the matter "for a plenary hearing before the [OAL] regarding [J.M.]'s

projected work schedule and income for the 2019 tax year."

      A different ALJ conducted the remand hearing on August 30, 2019. C.M.

and J.M. each provided testimony at the hearing. C.M. stated that J.M. worked

at ShopRite "temporarily" on a "part[-]time" basis; J.M. testified he "stopped

working at Shop[]Rite at the end of March" 2019, when he left college and

moved back home. He stated he only used his income from ShopRite "to pay

for [his] rent . . . , utilities and food expenses." J.M. further testified he had not

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                                          4
received any other income in 2019 and had not applied for unemployment

insurance.

      In her September 3, 2019 decision, the ALJ found that J.M.'s yearly gross

income for 2019 as of August 30 was $3,710.63. She further concluded that

J.M. had "not been employed for five months and there is no indication of future

employment." Thus, the ALJ's initial decision following our remand reversed

the agency's termination decision and reinstated Medicaid benefits for C.M.'s

household. On October 28, 2019, DMAHS rejected the ALJ's initial decision

and terminated petitioner's benefits effective February 1, 2019. In its October

28 decision, DMHAS acknowledged our remand order, but concluded that J.M.'s

updated income information was "not available to the [CWA] in December

2018, nor was it part of the record at the first . . . hearing before [the] ALJ

. . . ." Accordingly, it found "[i]t was reasonable for [the CWA] to predict that

Petitioner's son would remain employed at an estimated monthly salary of

$1,348.91," and that "Petitioner's household's eligibility was properly

terminated." C.M. sought to stay the October 28 order pending appeal and we

granted her request.

      C.M. asks us to consider the following arguments on appeal:

             POINT I: THE AGENCY VIOLATED THE INCOME
             COUNTING RULES OF THE AFFORDABLE CARE

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                                       5
            ACT [ACA] WHEN THEY INCLUDED THE
            EXEMPT INCOME OF A TAX-DEPENDENT INTO
            THE    HOUSEHOLD     UNIT'S   INCOME
            CALCULATION.

            POINT II: THE AGENCY INCORRECTLY USED
            PROJECTED    FUTURE   INCOME    OF THE
            APPLICANT'S TAX-DEPENDENT SON AS A
            MEANS TO TERMINATE THE HEALTH BENEFITS
            OF THE APPLICANT'S HOUSEHOLD. 3

      Appellate courts have a limited role in reviewing the decision of an

administrative agency. In re Stallworth, 208 N.J. 182, 194 (2011) (citing Henry

v. Rahway State Prison, 81 N.J. 571, 579 (1980)). As such, a strong presumption

of reasonableness is afforded to an agency's exercise of its statutorily delegated

responsibility, City of Newark v. Nat'l Res. Council, Dep't of Env't Prot., 82 N.J.

530, 539 (1980), and its factual findings are entitled to deference, Utley v. Bd.

of Rev., Dep't of Labor, 194 N.J. 534, 551 (2008) (citing Jackson v. Concord

Co., 54 N.J. 113, 117-18 (1969)).

3
  In her reply brief, C.M. raises two additional arguments, i.e., that "the agency
decision, which included the projected income of a tax dependent, does not
conform to federal regulations," and "the agency violated federal income
counting guidelines mandated by the [ACA] and did not adhere to the tax filing
concepts for the taxable year in which eligibility for Medicaid was being
determined." Given our conclusion that reversal is warranted and considering
these arguments were raised in C.M.'s reply brief, we need not address them .
See Pannucci v. Edgewood Park Senior Hous. – Phase 1, LLC, 465 N.J. Super.
403, 409-10 (App. Div. 2020) (citing State v. Smith, 55 N.J. 476, 488 (1970)
(noting impropriety of raising argument for first time in reply brief)).
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      We will not upset the determination of an administrative agency absent a

showing "that it was arbitrary, capricious or unreasonable, that it lacked fair

support in the evidence, or that it violated legislative policies[.]" Parascandolo

v. Dep't of Labor, Bd. of Rev., 435 N.J. Super. 617, 631 (App. Div. 2014)

(quoting Campbell v. Dep't of Civ. Serv., 39 N.J. 556, 562 (1963)). "Arbitrary

and capricious action of administrative bodies means willful and unreasoning

action, without consideration and in disregard of circumstances." Worthington

v. Fauver, 88 N.J. 183, 204 (1982) (quoting Bayshore Sewerage Co. v. Dept.

Environ. Protection, 122 N.J. Super. 184, 199 (Ch. Div. 1973)).

      Nonetheless, we are not tethered to an agency's interpretation of a statute

or its decision on a legal issue. See Univ. Cottage Club of Princeton N.J. Corp.

v. N.J. Dep't of Env't Prot., 191 N.J. 38, 48 (2007). Moreover, when an appellate

court directs an administrative agency to take action, "the appellate judgment

becomes the law of the case and the agency is under a peremptory duty not to

depart from it." Lowenstein v. Newark Bd. of Educ., 35 N.J. 94, 116-17 (1961).

Whether or not in agreement with the court, agencies have "a duty to obey the

mandate of [the Appellate Division] 'precisely as it is written.'" In re Denial of

Reg'l Contribution Agreement Between Galloway Twp. & City of Bridgeton,

418 N.J. Super. 94, 100-01 (App. Div. 2011) (quoting Flanigan v. McFeely, 20

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                                        7
N.J. 414, 420 (1956)). An appellate court's instructions "must be enforced as

written, and relief from its direction 'can be had only in the appellate court whose

judgment it is.'" Tomaino v. Burman, 364 N.J. Super. 224, 233 (App. Div. 2003)

(quoting In re Plainfield-Union Water Co., 14 N.J. 296, 303 (1954)). "[T]he

very essence of the appellate function is to direct conforming judicial action."

Ibid.; see also Pritchett v. State, 248 N.J. 85, 110, 113 (2021) (confirming that

any relief from the court's remand direction can be had only in the courts, even

if flawed).

      Medicaid is considered a "'cooperative federal-state endeavor' where, in

return for federal monies, states must comply with federal requirements." A.B.

v. Div. of Med. Assistance & Health Servs., 407 N.J. Super. 330, 342 (App. Div.

2009) (quoting L.M. v. State, Div. of Med. Assistance & Health Servs., 140 N.J.

480, 484 (1995)). Participating states must create "'reasonable standards . . . for

determining eligibility for and the extent of medical assistance . . . [that is]

consistent with the objectives' of the Medicaid program." L.M., 140 N.J. at 484

(quoting 42 U.S.C. § 1396a(a)(17)(A)). The purpose of Medicaid is to "provide

medical assistance to the poor[.]"       Estate of DeMartino v. Div. of Med.

Assistance & Health Servs., 373 N.J. Super 210, 217 (App. Div.

                                                                              A-1337-19
                                         8
2004) (quoting Mistrick v. Div. of Med. Assistance & Health Servs., 154 N.J.

158, 165 (1998)); see also 42 U.S.C. § 1396-1.

        The NJFC program was created "to help New Jersey's uninsured children

and certain low-income parents and guardians to have affordable health

coverage." S.J. v. Div. of Med. Assistance & Health Servs., 426 N.J. Super.

366, 368, n.1 (App. Div. 2012) (citations and internal quotation marks omitted).

As part of the NJFC program, DMAHS oversees the administration of Medicaid

benefits. See generally N.J.A.C. 10:78-1.1 to - 11.5. CWAs are required to

estimate a household's prospective income to determine its eligibility for

benefits. N.J.A.C. 10:78-4.2(a)(1). The CWA's "best estimate" of prospective

income is generally "based on the household unit's income for the month

preceding the date of application or redetermination."         Ibid.   However,

"[a]djustments shall be made to the estimated income to reflect changes in

income that either have occurred or which are reasonably anticipated to occur

which would affect the household unit's income during a period of eligibility."

Ibid.

        An applicant must "[c]omplete, with the assistance of the [CWA], as

needed, any forms required as part of the application process; and . . . [a]ssist

the [CWA] in securing evidence that verifies his or her statements regarding

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                                       9
eligibility." N.J.A.C. 10:78-2.1(c). The CWA then reviews the application

"for completeness, consistency, and reasonableness[.]"           N.J.A.C. 10:78-

2.1(b)(2).

      NJFC regulations require that income include "the income of all members

of the household unit." N.J.A.C. 10:78-4.3(a). The regulations go on to provide

that "natural or adoptive children under the age of 21" are members of the

household unit. N.J.A.C. 10:78-3.5(a)(1)(iii). Nevertheless, income eligibility

determinations for the expanded Medicaid program under the ACA are required

to be made pursuant to the federal income counting methodology known as the

MAGI method. 42 C.F.R. § 435.603(a)(2). Under federal regulations, income

of a dependent is not included in the household income when the dependent is

not required to file a federal tax return. 42 C.F.R. § 435.603(d)(2)(i). In that

regard, the applicable federal regulation states:

             The MAGI-based income of an individual who is
             included in the household of his or her natural, adopted
             or step-parent and is not expected to be required to file
             a tax return under section 6012(a)(1) of the Code for
             the taxable year in which eligibility for Medicaid is
             being determined, is not included in household income
             whether or not the individual files a tax return.

             [Ibid.]

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      Federal law requires that a tax return be filed for every individual having

taxable yearly gross income that equals or exceeds the exempt amount. 26

U.S.C. § 6012(a)(1). In 2019, a single dependent was required to file a federal

tax return if that individual's earnings were at least $12,200. Thus, we do not

fault the CWA for using the income information it had at its disposal for J.M. in

December 2018, calculating that he averaged earnings of $1,348.91 per month,

and projecting he would need to file a federal tax return for 2019.4 We also do

not question the CWA's December 2018 determination that based on J.M.'s

projected income, C.M.'s household income would exceed the household's

eligibility threshold. Likewise, we do not take issue with DMAHS finding in

May 2019 that the CWA was correct in projecting C.M.'s household income for

2019 rendered her ineligible for Medicaid benefits going forward.

      However, because we granted C.M. emergent relief in June 2019, and

remanded the matter for a hearing to reassess J.M.'s projected earnings for 2019,

the agency was bound to consider J.M.'s updated income information as revealed

during that August 2019 remand hearing. Such information included the ALJ's

4
   Although the calculation of J.M.'s monthly income varies throughout the
record, for purposes of this appeal, we accept the agency's calculation that J.M.'s
income averaged $1,348.91 per month, as this is the figure set forth in the
challenged order of October 28, 2019.

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                                       11
findings that J.M. left ShopRite as of March 23, 2019, that his gross income for

2019 was $3,710.63, and that he had "not been employed for five months and

there is no indication of a future employment opportunity for J.M." Importantly,

the ALJ also concluded, "J.M.'s yearly gross income of $3,710.63 would not

require him to file a tax return for the tax year of 2019." These findings were

amply supported in the record.

      On appeal, DMAHS does not take issue with any of the ALJ's findings.

Instead, it simply concludes the information disclosed during the remand

hearing we ordered was "not available to the [CWA] in December 2018 or during

the February 25, 2019 hearing." But because the agency was aware after the

remand hearing that J.M.'s projected income for 2019 fell far short of its initial

estimation, and that he would not be required to file a tax return for that calendar

year, we are satisfied it was not free to ignore this updated information as a basis

to reverse the September 3 order reinstating the Medicaid benefits for C.M.'s

household. See N.J.A.C. 10:78-4.2(a)(1) (compelling the agency to account for

"changes in income that . . . have occurred" when calculating prospective

income).

      In sum, given the unusual circumstances in this case where we ordered the

agency to conduct a remand hearing for the express purpose of having it reassess

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                                        12
J.M.'s projected income for 2019, as well as the likelihood he would need to file

a federal tax return for 2019, we are persuaded DMAHS erred by failing to

consider the supplemental information flowing from that hearing and by

rejecting the ALJ's September 3, 2019 decision reinstating Medicaid benefits for

C.M.'s household.

      Reversed. Because we are unaware of the current financial circumstances

of C.M.'s household, we remand for the CWA to consider the family's current

eligibility status. We do not retain jurisdiction.

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