Court Opinion

ID: 4431155
Source: CourtListenerOpinion
Date Created: 2019-08-20 19:53:01.853289+00
Date Added: 2024-06-11T14:23:23.845398
License: Public Domain

NOT FOR PUBLICATION WITHOUT THE
                      APPROVAL OF THE APPELLATE DIVISION
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      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-5179-16T4

V.S.,

        Petitioner-Appellant,

v.

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

     Respondents-Respondents.
_________________________________

              Submitted June 5, 2018 – Decided June 18, 2018

              Before Judges Hoffman and Gilson.

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

              John Pendergast, attorney for appellant.

              Gurbir S. Grewal, Attorney General, attorney
              for respondent Division of Medical Assistance
              and Health Services (Melissa H. Raksa,
              Assistant Attorney General, of counsel; Angela
              Juneau Bezer, Deputy Attorney General, on the
              brief).

PER CURIAM
       Appellant V.S. appeals from a June 12, 2017 final agency

determination by the Director of the Division of Medical Assistance

and   Health    Services    (DMAHS)    that      denied    her   application       for

Medicaid.      We affirm.

                                           I

      Appellant is a nursing facility resident; her adult son is

her legal guardian, and she is represented by counsel. On November

25,   2015,    appellant's     authorized        representative      submitted        a

Medicaid    application     with     the   Bergen    County      Board   of    Social

Services (BCBSS) on her behalf. The application stated appellant's

primary    sources   of     income    were     social     security   and      pension

benefits. It also stated she maintained TD Bank checking accounts,

Prudential investment accounts, and had recently sold a single

family home in Saddle Brook.

      The BCBSS replied to appellant's application with a notice

requesting information verifying the information included in her

application; among other things, it requested bank statements from

August 2015 through November 2015.              The BCBSS denied appellant's

application for failure to produce those documents1 after she

failed to respond to the notice.               Appellant requested a hearing,

1
   Specifically, the BCBSS denied the application for failure "to
provide [b]ank statements from [August] 2015 to [December] 2015."

                                           2                                  A-5179-16T4
and subsequently, the matter was transferred to the Office of

Administrative Law.

      On April 26, 2017, an administrative law judge (ALJ) issued

an   initial   decision     and   concluded      the   BCBSS    properly    denied

appellant's Medicaid application due to failure to produce the

requested      documentation.         Specifically,       the     ALJ    rejected

appellant's arguments that state and federal regulations required

the BCBSS to obtain the documentation itself, rather than requiring

appellant to produce the documents.

      On June 12, 2017, DMAHS issued a final                    agency   decision

adopting the ALJ's initial decision.             DMAHS found,

            The   credible   evidence    in   the   record
            demonstrates that [appellant] failed to
            provide the needed information prior to the
            January 28, 2017 denial of benefits. Without
            this information, [the] BCBSS was unable to
            complete its eligibility determination and the
            denial was appropriate.

                 . . . [DMAHS] agree[s] with the ALJ that
            there is nothing in the state or federal law
            that either excuses [appellant] from her
            obligation to obtain documents needed to
            verify her eligibility or requires [the] BCBSS
            to obtain documents not available through the
            [Asset Verification System] . . . .

This appeal followed.

                                       II

      An appellate court will not reverse the decision of an

administrative     agency    unless   it    is   "arbitrary,      capricious      or

                                       3                                   A-5179-16T4
unreasonable or . . . not supported by the substantial credible

evidence in the record as a whole."               Barrick v. State, 218 N.J.

247, 259 (2014) (quoting In re Stallworth, 208 N.J. 182, 194

(2011)).     In cases when an agency head reviews the fact-findings

of an ALJ, a reviewing court must uphold the agency head's findings

even if they are contrary to those of the ALJ, if supported by

substantial credible evidence.          In re Silberman, 169 N.J. Super.

243, 255-56 (App. Div. 1979).

    New    Jersey   participates    in      the   federal    Medicaid      program

pursuant to the New Jersey Medical Assistance and Health Services

Act, N.J.S.A. 30:4D-1 to -19.5.             Eligibility for Medicaid in New

Jersey is governed by regulations adopted in accordance with the

authority granted to the Commissioner of the Department of Human

Services.     N.J.S.A. 30:4D-7.         DMAHS is the agency within the

Department    of    Human    Services    that     administers   the     Medicaid

program.     N.J.S.A. 30:4D-5; N.J.A.C. 10:49-1.1.                  Accordingly,

DMAHS is charged with the responsibility for safeguarding the

interest of the New Jersey Medicaid program and its beneficiaries.

N.J.A.C. 10:49-11.1(b).        DMAHS is required to manage the State's

Medicaid program in a fiscally responsible manner.              See Dougherty

v. Dep't of Human Servs., 91 N.J. 1, 4-5 (1982).

    The    local    county   welfare    agency      (CWA),   here    the    BCBSS,

evaluates    Medicaid   eligibility.          N.J.S.A.   30:4D-7a;      N.J.A.C.

                                        4                                  A-5179-16T4
10:71-2.2(a), -3.15.            Eligibility must be established based on the

legal requirements of the program.               N.J.A.C. 10:71-3.15.      The CWA

must verify the equity value of resources through appropriate and

credible sources.              If the applicant's resource statements are

questionable or the identification of resources is incomplete,

"the CWA shall verify the applicant's resource statements through

one or more third parties."             N.J.A.C. 10:71-4.1(d)(3).

      "The process of establishing eligibility involves a review of

the     application             for     completeness,       consistency,         and

reasonableness."        N.J.A.C. 10:71-2.9.        Applicants must provide the

CWA with verifications, which are identified for the applicant.

The applicant must "[a]ssist the CWA in securing evidence that

corroborates      his     or    her   statements . . . ."      N.J.A.C.     10:71-

2.2(e)(2).        The applicant's statements in the application are

evidence and must substantiate the application with "corroborative

information from" pertinent sources.               N.J.A.C. 10:71-3.1(b).

      The   CWA    must    timely      process    the   application.       See    42

U.S.C. § 1396a(a)(3); see also 42 C.F.R. § 435.911(c); N.J.A.C.

10:71-2.3.        It must send each applicant written notice of the

agency's decision on his or her application.                N.J.A.C. 10:71-8.3.

The CWA should deny applications when the applicant fails to timely

provide verifications.            See N.J.A.C. 10:71-2.2(e), -2.9, -3.1(b).

                                           5                               A-5179-16T4
                                      III

     On appeal appellant reiterates the arguments she presented to

the ALJ and DMAHS, alleging state and federal law require the

BCBSS to make an initial effort in obtaining the information it

requested from her.       We disagree, and affirm substantially for the

reasons stated in the ALJ's initial decision, which DMAHS adopted.

     Appellant    first    argues    N.J.A.C.     10:71-2.2,    -2.10,     -4.1,

and -4.2 require DMAHS "caseworkers to assist Medicaid applicants

in   exploring   their    eligibility"      and   "conduct     [a]    collateral

investigation     to   verify,      supplement,     or   clarify      essential

information."     Appellant argues the BCBSS failed to contact her

financial   institution     to   verify     her   resources,    and   therefore

erroneously denied her application.

     Appellant's argument, however, ignores N.J.A.C. 10:71-2.2(e),

which provides:

            As a participant in the application process
            an applicant shall:

            1. Complete, with the assistance from the CWA
            if needed, any forms required by the CWA as a
            part of the application process;

            2. Assist the CWA in securing evidence that
            corroborates his or her statements; and

            3. Report promptly any change affecting his
            or her circumstances.

            [(Emphasis added).]

                                       6                                 A-5179-16T4
DMAHS    appropriately          interpreted     that    regulation       as    requiring

Medicaid applicants to supplement their applications and verify

information      CWAs     find    relevant.       Here,        the   BCBSS     requested

appellant provide bank statements, and when she failed to do so,

it correctly denied her application.                  Moreover, as the ALJ noted,

appellant's Medicaid application explicitly stated she did not

require assistance in its completion.                  Accordingly, DMAHS did not

act arbitrarily, capriciously, or unreasonably in denying her

application.

       Appellant further argues that under 42 C.F.R. § 435.948(b),

the    BCBSS     had    the     "affirmative     duty     to    obtain      information

regarding" her eligibility.              She argues the BCBSS breached that

duty    when    it     failed    to    obtain   her    bank     information      via     an

electronic asset verification system (AVS), or by other means.

See 42 U.S.C. § 1396w (requiring states to implement AVS).

       42 C.F.R. § 435.948(b) provides:                "To the extent           that the

information      identified       in    paragraph      (a)2    of    this     section    is

2
    42 C.F.R. § 435.948(a) requires DMAHS to request financial
eligibility information "from other agencies in the State and
other States and Federal programs":

               related to wages, net earnings from self-
               employment, unearned income and resources from
               the State Wage Information Collection Agency
               (SWICA), the Internal Revenue Service (IRS),
               the Social Security Administration (SSA), the

                                            7                                     A-5179-16T4
available through the electronic service established in accordance

with    § 435.949      of    this    subpart,      the    agency    must      obtain   the

information through such service."                 42 C.F.R. § 435.949, entitled

"Verification       of      information      through      an   electronic       service,"

applies to information available from "[f]ederal agencies and

other data sources, including the SSA, the Department of Treasury,

and the Department of Homeland Security."

       Here,     appellant         inaccurately          interprets       the     federal

regulations      as    requiring      the     BCBSS      to    obtain   the     requisite

supplemental information for her.                   There is no regulation that

requires       agencies      to     obtain       information      about    a     Medicaid

applicant's bank records from an electronic service. See 42 C.F.R.

§ 435.952(c).         There is also no regulation that precludes the CWA

from    obtaining        such     information      directly      from     the    Medicaid

applicant.       Ibid.

       As the ALJ noted, "federal laws regarding [DMAHS's] use of the

AVS system do not apply [when] the information needed by the [CWA]

is not on the AVS system and [when] the documents needed by the

               agencies administering the State unemployment
               compensation laws, the State-administered
               supplementary payment programs[,] . . . and
               any state program administered under a plan
               approved under Titles I, X, XIV, or XVI of the
               Act[,and i]nformation related to eligibility
               or enrollment from the Supplemental Nutrition
               Assistance Program . . . .

                                             8                                    A-5179-16T4
[CWA] (bank statements) are not obtainable from the AVS system,

but   only   from   the    bank   itself."   Here,     the   BCBSS    requested

appellant provide bank account information — this is not data

available from federal agencies, but rather a private financial

institution.

      Accordingly, appellant's arguments lack merit, and DMAHS did

not   act    arbitrarily    or    capriciously   in   denying   her   Medicaid

application.

      Affirmed.

                                        9                               A-5179-16T4