The New Jersey Superior Court affirmed the decision of the Division of Medical Assistance and Health Services (Division) that a recipient was no longer clinically eligible for nursing facility services under Medicaid. R.G. v. Div. of Med. Assist. & Health Serv., No. A-1766-23 (N.J. Super. Ct. Oct. 16, 2025).
In January 2021, New Jersey’s Office of Community Choice Options (OCCO) performed an assessment of R.G. It determined that she was eligible for Medicaid and in need of nursing facility level of care. She was admitted to a nursing home. In 2021 and 2022, OCCO did not do an annual reassessment of eligibility because of the COVID-19 pandemic; however, in 2021 and 2022, R.G.’s managed care organization determined that she had completed rehabilitation and did not need nursing facility level of care. In its 2023 reassessment, OCCO notified R.G. that she was ineligible for nursing facility level of care under N.J. Admin. Code § 8:85-2.1.
R.G. challenged OCCO’s decision. The administrative law judge (ALJ) reversed OCCO’s decision, rejecting a nurse’s assessment on the basis that R.G. did not understand the assessment and the nurse did not speak to R.G.’s physicians. Based on R.G.’s physicians’ testimony, the ALJ determined that R.G. met the clinical criteria for nursing facility level of care. However, the Division reversed the ALJ’s decision and upheld OCCO’s determination that R.G. was ineligible for nursing facility level of care. R.G. appealed the Division’s decision.
The New Jersey Superior Court determined that the Division’s determination was supported by sufficient credible evidence in the record and was not arbitrary, capricious, or unreasonable. The court noted that adults on Medicaid must meet both financial and health-related criteria to be eligible for nursing facility care under Medicaid. Clinical eligibility is determined by staff designated by OCCO based on a comprehensive needs assessment demonstrating that the individual needs nursing facility services as set forth in N.J. Admin. Code § 10:166-2.1(a) and N.J. Admin. Code § 10:166-2.2.
The record showed that the nurse who performed the comprehensive needs assessment met with R.G., who told the nurse that she could independently perform all activities of daily living (ADLs). Further, the nurse observed R.G. ambulating and moving from a standing to a sitting position without assistance, using her walker. The nurse also examined the charts from R.G.’s facility, which included notes by medical and other staff, and conferred with staff and R.G.’s social worker, all of whom indicated that R.G. did not need help with ADLs. The court rejected R.G.’s argument that the nurse’s assessment was not comprehensive because she did not speak to R.G.’s doctor. The Division was not required to consult with a physician under the relevant regulation. Further, the nurse did not rely on R.G.’s own statements about her ability to perform ADLs but confirmed R.G.’s statements by reviewing other information. Because R.G. had not met her burden to show that the Division’s decision was arbitrary, capricious, or unreasonable, the court affirmed.
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