NOT FOR PUBLICATION WITHOUT THE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-2025-15T2
P.N.,
Petitioner-Appellant,
v.
DIVISION OF MEDICAL ASSISTANCE
AND HEALTH SERVICES and UNION
COUNTY BOARD OF SOCIAL SERVICES,
Respondents-Respondents.
_____________________________________
Submitted July 18, 2017 – Decided July 28, 2017
Before Judges Reisner and Suter.
On appeal from the Division of Medical
Assistance and Health Services, Department of
Human Services.
Thomas M. Wolfe, attorney for appellant.
Christopher S. Porrino, Attorney General,
attorney for respondent Division of Medical
Assistance and Health Services (Melissa H.
Raksa, Assistant Attorney General, of counsel;
Melissa Bayly, Deputy Attorney General, on the
brief).
PER CURIAM
P.N. appeals the November 17, 2015 final agency decision of
the Division of Medical Assistance and Health Services (DMAHS)
that denied her application for Medicaid benefits. We affirm.
In October 2013, a paralegal in the office of P.N.'s attorney
called the Union County Welfare Board (CWB) to request information
about Medicaid for P.N., and testified she was told a letter would
be sent to her scheduling an appointment. P.N. was physically
eligible for Medicaid, based upon an earlier pre-administrative
screening. She resided in an assisted-living facility.
When P.N.'s attorney did not receive an appointment or a
denial letter, in March 2014, he sent a letter to a supervisor at
CWB advising that P.N. needed to apply for Medicaid. The letter
requested "an appointment to present this Medicaid application."
CWB responded two months later, advising P.N. to attend an
appointment on June 13, 2014, and to bring with her various
financial documents.
P.N.'s application for Medicaid was submitted on June 13,
2014, but she did not thereafter provide all the information
required to determine her eligibility. On November 7, 2014, P.N.'s
counsel was advised that P.N.'s application would be denied unless
information needed to verify her income was provided by November
21, 2014. On November 26, 2014, P.N's application for Medicaid
was denied because she had not provided "numerous bank statements,
2 A-2025-15T2
bills and other documentation. [She] only provided a part of the
information requested. [Her] application [was] denied for failing
to provide the necessary verifications to process [the case]."
At P.N.'s request, a hearing was conducted concerning the
denial of her application. On October 7, 2015, the Administrative
Law Judge's initial decision affirmed the denial of Medicaid
benefits to P.N., finding she was "not eligible for Medicaid
because she failed to provide the requested verifications, and
even if she had, her resources . . . exceeded the limit at the
operative times." The November 17, 2015 final agency decision
upheld the denial of benefits as appropriate because P.N's June
2014 application for Medicaid did not provide the needed
information to determine eligibility before the November 26, 2014
denial.
On appeal, P.N. contends DMAHS's final agency decision was
arbitrary and capricious by failing to examine all the facts, and
further, that DMAHS should be estopped from denying the application
retroactively to October 2013.
We review an agency's decision for the limited purpose of
determining whether its action was arbitrary, capricious or
unreasonable. "An administrative agency's decision will be upheld
'unless there is a clear showing that it is arbitrary, capricious,
or unreasonable, or that it lacks fair support in the record.'"
3 A-2025-15T2
R.S. v. Div of Med. Ass't and Health Servs., 434 N.J. Super. 250,
261 (App. Div. 2014) (quoting Russo v. Bd. of Trs., Police &
Firemen's Ret. Sys., 206 N.J. 14, 25 (2011)). "The burden of
demonstrating that the agency's action was arbitrary, capricious
or unreasonable rests upon the [party] challenging the
administrative action." E.S. v. Div. of Med. Assistance & Health
Servs., 412 N.J. Super. 340, 349 (App. Div. 2010) (alteration in
original) (quoting In re Arenas, 385 N.J. Super. 440, 443-44 (App.
Div.), certif. denied, 188 N.J. 219 (2006)).
"Medicaid is a federally-created, state-implemented program
that provides 'medical assistance to the poor at the expense of
the public.'" Matter of Estate of Brown, 448 N.J. Super. 252, 256
(App Div.) (quoting Estate of DeMartino v. Div. of Med. Assistance
& Health Servs., 373 N.J. Super. 210, 217 (App. Div. 2004), certif.
denied, 182 N.J. 425 (2005); 42 U.S.C.A. § 1396-1), certif. denied,
__ N.J. __ (2017). To receive federal funding, the State must
comply with all the federal statutes and regulations. Harris v.
McRae, 448 U.S. 297, 301, 100 S. Ct. 2671, 2680, 65 L. Ed. 2d 784,
794 (1980).
In New Jersey, the Medicaid program is administered by DMAHS
pursuant to the New Jersey Medical Assistance and Health Services
Act, N.J.S.A. 30:4D-1 to -19.5. The county welfare boards evaluate
eligibility. "In order to be financially eligible, the applicant
4 A-2025-15T2
must meet both income and resource standards." Brown, supra, 448
N.J. Super. at 257 (citing N.J.A.C. 10:71-3.15).
Under DMAHS's regulations, it establishes "policy and
procedures for the application process." N.J.A.C. 10:71-2.2(b).
The county welfare boards exercise direct responsibility in the
application process to . . . receive applications." Id. at 2.2(c).
They also "[a]ssure the prompt and accurate submission of
eligibility data." Id. at 2.2(c)(5). The regulations establish
time frames to process an application, with the "date of effective
disposition" being the "effective date of the application" where
the application has been approved. N.J.A.C. 10:71-2.3(b)(1).
DMAHS's final agency decision was not arbitrary, capricious
or unreasonable. P.N. did not dispute that her written application
for Medicaid was submitted in June 2014, or that information was
missing to determine her eligibility for benefits. When the
verifying information was not provided, DMAHS properly denied the
application. P.N. provides no authority for her contention that
the phone call in October 2013 could substitute for a formal
application consistent with DMAHS's regulations.1 Moreover, DMAHS
1
To the extent P.N. may have "outstanding unpaid medical bills
incurred within the three month period prior to the month of
application for Medicaid Only," the regulations provide a
procedure for making application for retroactive eligibility for
Medicaid, see N.J.A.C. 10:71-2.16, but the triggering date is the
"month of application," not a phone call.
5 A-2025-15T2
was correct to deny an application that did not have the
information necessary to verify eligibility because Medicaid is
intended to be a resource of last resort and is reserved for those
who have a financial or medical need for assistance. See N.E. v.
Div. of Med. Assistance & Health Servs., 399 N.J. Super. 566, 572
(App. Div. 2008).
After carefully reviewing the record and the applicable legal
principles, we conclude that P.N.'s further arguments are without
sufficient merit to warrant discussion in a written opinion. R.
2:11-3(e)(1)(E).
Affirmed.
6 A-2025-15T2
P.N. VS. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES (DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES)
Combined Opinion