Medicaid Applicant Who Submitted Proof of Eligibility Late Should Receive Benefits

A New Jersey appeals court rules that a Medicaid applicant who was eligible for benefits on the day he submitted his application, but who submitted proof of his eligibility after an initial denial notice, should receive benefits. W.M. v. Division of Medical Assistance and Health Services (N.J. Super. Ct., App. Div., No. A-4164-16T2, June 26, 2018).

W.M. entered a nursing home and applied for Medicaid. The state denied the application due to excess resources, including a life insurance policy. The letter stated that if W.M. had surrendered any of these resources, he should provide verification. W.M. submitted verification that he had surrendered the life insurance policy two months before applying for Medicaid. The state responded that this was inadequate and denied the application.

W.M. appealed, and the administrative law judge (ALJ) ruled that the evidence showed W.M. was eligible for benefits on the date he submitted the application. The Medicaid agency director overruled the ALJ, and W.M. appealed to court.

The New Jersey Superior Court, Appellate Division, reverses, finding that the state's "persistence in denying this meritorious claim based on the alleged untimeliness of W.M.'s document submission was arbitrary, capricious and unreasonable." The court notes that the denial letters invited W.M. to submit additional information, and the additional information showed that W.M. was eligible for benefits on the day he submitted the application.

For the full text of this decision, go to: https://www.njcourts.gov/attorneys/assets/opinions/appellate/unpublished/a4164-16.pdf?cacheID=9IeQfCA

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