by Jose D. Roman | Mar 1, 2026 | Consumer Advocacy, Legal Bulletin, Medicaid, Medicaid Updates
As a New Jersey Medicaid lawyer, I’m often asked whether immigrants—especially those who are undocumented—can qualify for Medicaid or other forms of public health coverage. The answer is complicated, because eligibility depends on a mix of federal law, state initiatives, and funding streams that shift with each legislative cycle. The short answer is that New Jersey offers more inclusive health coverage than most states, but many immigrants still face limits depending on their immigration status.
Lawfully Present vs. Undocumented: A Crucial Distinction
Federal Medicaid law draws a sharp line between immigrants who are “lawfully present” and those who are “undocumented.” Lawfully present immigrants include lawful permanent residents (green card holders), refugees, asylees, victims of trafficking, certain humanitarian parolees, and others permitted to live in the U.S. under federal immigration law.
Many of these immigrants can qualify for Medicaid, though most must first wait five years after obtaining status before they become eligible. Historically, refugees, asylees, and trafficking victims were exempt from that five-year bar and could access coverage immediately. As explained below, the One Big Beautiful Bill Act (OBBBA) has significantly changed this going forward, with major provisions taking effect October 1, 2026.
By contrast, undocumented immigrants—those without lawful status—cannot enroll in full Medicaid coverage under federal law. But in New Jersey, there are exceptions and state-funded programs that fill some of the gaps.
New Jersey’s State Initiatives: Expanding Coverage for Children and Families
One of the most significant New Jersey state programs is Cover All Kids. Enacted into law in 2021, the program was implemented in phases, with full coverage for undocumented children taking effect on January 1, 2023, under Governor Murphy’s administration. It allows all children under 19 to receive NJ FamilyCare coverage regardless of immigration status, as long as they meet the income and residency rules. It is a groundbreaking policy that recognizes every child’s need for health care, no matter where they were born. It’s important to understand how it’s funded. Because federal Medicaid and Children’s Health Insurance Program (CHIP) funds cannot be used for undocumented children, Cover All Kids is paid for entirely by New Jersey.
New Jersey also provides coverage for pregnant women, though the scope depends on immigration status. U.S. citizens and lawfully present immigrants with low are eligible for full NJ FamilyCare/Medicaid coverage during pregnancy, with postpartum coverage continuing for 12 months after delivery. Undocumented women who do not qualify for full Medicaid may be eligible for the NJ Supplemental Prenatal and Contraceptive Program (NJSPCP), which covers outpatient prenatal and family planning services. Emergency labor and delivery for undocumented women may be covered separately under Emergency Medicaid, described below.
Emergency Coverage for All
Even for those who don’t qualify for Medicaid benefits, emergency medical care remains available. Through the Medical Emergency Payment Program (commonly called Emergency Medicaid), immigrants—regardless of status—can receive coverage for treatment of life-threatening conditions, including labor and delivery.
This program is not purely state-funded. Federal law allows states to receive federal Medicaid matching funds for emergency services provided to individuals who are otherwise Medicaid-eligible but not lawfully present. New Jersey is a Medicaid expansion state, meaning it currently receives approximately 90% federal reimbursement for these emergency services, with the state covering the remainder. Hospitals remain legally required under the federal Emergency Medical Treatment and Labor Act to provide emergency stabilization to any patient regardless of immigration status or ability to pay. Only true emergencies qualify for Emergency Medicaid; any non-emergency care for undocumented immigrants must be fully funded by the state if offered at all.
The “One Big Beautiful Bill” and Its Sweeping Impact on Immigrant Coverage
The One Big Beautiful Bill Act (OBBBA), signed into law on July 4, 2025, makes the most far-reaching changes to immigrant Medicaid eligibility since the 1996 welfare reform law. While much public attention has focused on work requirements and hospital reimbursements, the OBBBA’s effects on immigrant health coverage are equally significant.
The key changes for New Jersey residents are:
- Refugees, asylees, humanitarian parolees, and trafficking victims lose federal Medicaid and CHIP eligibility entirely (effective October 1, 2026). Under prior law, these groups were exempt from the five-year waiting period and could access Medicaid immediately upon receiving status. Under the OBBBA, they are removed from the definition of “qualified alien” for Medicaid purposes altogether. Only green card holders (lawful permanent residents), certain Cuban and Haitian entrants, and citizens of Freely Associated States remain eligible for federal Medicaid. States may still choose to cover lawfully residing children and pregnant women using their own funds.
- Emergency Medicaid federal reimbursement is reduced (effective October 1, 2026). For undocumented immigrants who would otherwise be Medicaid-eligible, the federal matching rate for emergency services drops from New Jersey’s current 90% expansion rate to approximately 50–65%. This does not eliminate emergency coverage, but it significantly increases the financial burden on the state.
- Cover All Kids remains intact because it is funded entirely by New Jersey for undocumented children. The OBBBA does not penalize states for using their own dollars to cover undocumented children.
These changes mean that thousands of New Jersey residents who are lawfully present in the United States—people who went through the legal process to obtain refugee, asylee, or humanitarian parole status—will lose access to federally funded health coverage starting October 2026, unless Congress acts.
What Democrats Want to Restore
In response, Democratic lawmakers in Congress have proposed measures to reverse several of these cuts. Their efforts aim to restore the federal Medicaid matching funds eliminated under the OBBBA, particularly for emergency medical services and for programs that assist lawfully present immigrants whose eligibility was stripped.
The Democratic proposals also seek to eliminate new work requirements, restore funding to rural hospitals, and extend enhanced ACA premium tax credits (topics not covered in this article). As the nonpartisan Kaiser Family Foundation has noted, these proposals do not create new eligibility for undocumented immigrants (who were already ineligible for federally funded coverage before the OBBBA). Rather, they aim to restore coverage for lawfully present immigrants like refugees and asylees, and to ensure that mixed-status families don’t lose access to care because of shifting political priorities or administrative red tape.
In addition, Democrats want to reinstate the higher federal cost-sharing for emergency services provided to immigrants without legal status—in practical terms, restoring the 90% reimbursement for states like New Jersey that maintain immigrant-inclusive safety nets.
Where Things Stand Now
New Jersey continues to be one of the more immigrant-friendly states when it comes to health coverage. Undocumented children remain protected under Cover All Kids. Lawfully present pregnant women receive full Medicaid with 12 months of postpartum coverage. Emergency care remains available to all through Emergency Medicaid, even as the federal government will cover a lower share of those costs beginning in October 2026.
However, the most significant near-term threat is to lawfully present immigrants—refugees, asylees, and humanitarian parolees—who will lose federal Medicaid eligibility entirely under the OBBBA unless that provision is reversed. Whether New Jersey chooses to bridge the gap with state dollars, as it has done for undocumented children, remains to be seen.
From a policy perspective, the direction of federal law will determine how sustainable New Jersey’s approach remains. If the state continues to shoulder the costs of inclusivity while federal funding shrinks, the long-term pressure on the state budget will grow. On the other hand, restoring the federal match for emergency and qualified immigrant coverage could stabilize the system and maintain access for some of New Jersey’s most vulnerable residents.
Final Thoughts
As a Medicaid lawyer practicing in New Jersey, I see firsthand how these laws affect real people. Families trying to navigate complex immigration and health systems often face confusion, fear, and financial strain. Understanding who qualifies—and how programs like Cover All Kids and Emergency Medicaid are funded—is essential for both residents and practitioners.
The bottom line is this: New Jersey has built a relatively compassionate model that balances legal restrictions with state-funded solutions. But that balance depends heavily on federal cooperation. With the OBBBA’s sweeping changes to lawfully present immigrant eligibility and the ongoing debate in Congress, the future of immigrant health coverage in New Jersey will likely hinge on how much support Washington is willing to restore.
by Jose D. Roman | Oct 7, 2025 | Legal Bulletin, Medicaid, Medicaid Planning, Medicaid Updates
When applying for Medicaid or completing annual renewal paperwork in New Jersey, deadlines are critical. Missing a due date for requested documents can lead to a denial of the application or termination of benefits—sometimes with devastating consequences. But what happens if you mail documents on time but the agency later claims they were received late or not at all? Can you rely on the legal principle called the Mailbox Rule to prove that you provided a timely response?
What Is the Mailbox Rule?
The Mailbox Rule is a common-law legal doctrine that creates a rebuttable presumption of receipt. If a letter is properly addressed, stamped, and mailed, the law presumes it was received by the addressee in the normal course of mail delivery. The New Jersey Supreme Court affirmed this rule in SSI Medical Services, Inc. v. State, 146 N.J. 614, 621 (1996), explaining:
Where the evidence shows that a letter properly directed was mailed and not returned, a presumption arises that it reached its destination in due course of mail and was actually received by the person to whom it was addressed.
Medicaid and the Limits of the Mailbox Rule: A.N. v. Passaic County (2024)
In a 2024 Medicaid Fair Hearing matter, A.N. v. Passaic County Board of Social Services, an applicant submitted a Medicaid application on January 31, 2024. The agency sent a written request for income verification, giving a deadline of March 2. The applicant later claimed he mailed the requested documents, but the county said they were never received—and no proof of mailing was provided.
In reviewing the case, the administrative law judge acknowledged the Mailbox Rule under SSI Medical Services and the traditional presumption that mailed documents are received. However, the judge concluded that there was no evidence that the requested documents were mailed or emailed. Because the applicant failed to provide reliable proof of mailing (e.g., a copy of postmarked mail, certified mail receipt, tracking number, fax confirmation, sent email), the agency’s determination stood, and the application was denied.
Key Takeaways
- The mailbox rule is recognized in the Medicaid application context in New Jersey.
- Applicants bear the burden of proving compliance with submission deadlines.
- Testimony of mailing alone is likely not sufficient for court – you need to keep proof of mailing.
Best Practices for Medicaid Applicants
- Use certified or priority mail with a tracking number and return receipt.
- Retain copies of all submitted documents, including the envelope with the postmark.
- Follow up with the agency to confirm receipt—by phone, email, or in writing—and document all communications.
- Do not rely solely on regular mail, especially for time-sensitive or high-stakes Medicaid communications.
Conclusion
While the Mailbox Rule offers some protection in many legal contexts, it provides limited security in New Jersey Medicaid matters. Administrative agencies and courts expect actual, verifiable receipt of applications, verifications, and renewals. If you or your client is dealing with Medicaid, don’t take chances—take steps to ensure every document is received and acknowledged.
by Jose D. Roman | Apr 10, 2025 | Consumer Advocacy, Legal Bulletin, Medicaid, Medicaid Planning, Medicaid Updates
The situation is all too common for Elder Law attorneys and their Medicaid applicant clients – a denial or termination of benefits due to supposedly insufficient documents, even when the agency is provided with everything it asked for. A recent decision, M.L. v. Essex County Division of Family Assistance and Benefits, A-0884-23 (March 18, 2025), highlights the typical scenario where the agency arbitrarily denies an application for reasons not apparent until after the fact. The court’s ruling underscores the importance of procedural fairness in Medicaid eligibility determinations and provides a summary of the law for advocates to use when pushing back on denials or terminations based on insufficient documents.
Case Background
M.L., an elderly nursing home resident, applied for Medicaid benefits on March 31, 2023. The Essex County Division of Family Assistance and Benefits initially requested additional documentation, including bank statements from Wells Fargo, to verify financial eligibility. M.L. promptly requested and obtained these records from his bank and provided copies to Essex County before the deadline. However, Essex County denied his application, claiming that he provided insufficient financial documentation and had unexplained withdrawals. M.L. promptly filed an appeal, as well as a second Medicaid application. The second application contained additional records, including records from a newly discovered Citizens Bank account. During the appeal, M.L. argued that he had substantially complied with Essex County’s requests. An administrative law judge (ALJ) agreed, ruling that M.L. had satisfied Medicaid eligibility requirements. However, the Division of Medical Assistance and Health Services (DMAHS) rejected the ALJ’s decision, affirming the original denial on the grounds that M.L. failed to provide all required documentation within the designated timeframe, including the additional statements from the Citizens Bank account.
Appellate Court’s Summary of the Law
Upon review, the Appellate Division found DMAHS’s final decision to be arbitrary, capricious, and unreasonable. The Court provided a useful review of New Jersey regulatory law that applies in these circumstances, which is summarized below.
The local County Welfare Agency (CWA) and its caseworkers “exercise direct responsibility in the application process to . . . receive applications.” N.J.A.C. 10:71-2.2(c)(2). The caseworker is charged with evaluating an applicant’s eligibility for Medicaid benefits. N.J.S.A. 30:4D-7a; N.J.A.C. 10:71-2.2(a); N.J.A.C. 10:71-3.15. “The process of establishing eligibility involves a review of the application for completeness, consistency, and reasonableness.” N.J.A.C. 10:71-2.9.
While the applicant is “the primary source of information,” the caseworker is responsible for making “the determination of eligibility and to use secondary sources when necessary, with the applicant’s knowledge and consent.” N.J.A.C. 10:71-1.6(a)(2). The caseworker is not limited in the use of secondary sources to obtain necessary verification information. N.J.A.C. 10:71-4.1(d)(3) states:
The CWA shall verify the equity value of resources through appropriate and credible sources . . . . If the applicant's resource statements are questionable, or there is reason to believe the identification of resources is incomplete, the CWA shall verify the applicant's resource statements through one or more third parties.
The applicant is responsible for cooperating fully with the verification process if the caseworker must contact a third party to verify an applicant’s resources. N.J.A.C. 10:71-4.1(d)(3)(i). The agency may perform a collateral investigation to “verify, supplement or clarify essential information.” N.J.A.C. 10:71-2.10(b).
Under N.J.A.C. 10:71-2.2, the caseworker must communicate with the applicant regarding the claimed deficiencies and then, under N.J.A.C. 10:71-2.10(b), provide an opportunity for the applicant to verify, supplement, or clarify the information before denying an application.
N.J.A.C. 10:71-2.2(e)(1) to (3) requires an applicant to:
- Complete, with assistance from the CWA if needed, any forms required by the CWA as a part of the application process;
- Assist the CWA in securing evidence that corroborates his or her statements; and
- Report promptly any change affecting his or her circumstances.
N.J.A.C. 10:71-2.2(c)(1) to (5) requires a caseworker to:
- Inform the applicants about the purpose and eligibility requirements for Medicaid Only,
- Inform them of their rights and responsibilities under its provisions and inform applicants of their right to a fair hearing;
- Receive applications;
- Assist . . . applicants in exploring their eligibility for assistance;
- Make known to . . . applicants the appropriate resources and services both within the agency and the community, and, if necessary, assist in their use; and
- Assure the prompt and accurate submission of eligibility data to the Medicaid status files for eligible persons and prompt notification to ineligible persons of the reasons for their ineligibility.
State agencies must “turn square corners” with the public they serve in carrying out their statutory responsibilities. W.V. Pangborne & Co. v. N.J. Dep't of Transp., 116 N.J. 543, 561–62 (1989). When this bedrock principle is read together with the above regulations, the dispositive legal conclusion is that both the applicant and the County have a duty under the regulations to take affirmative steps to communicate with each other regarding a pending application. The scope of this joint duty clearly includes the parties’ efforts to clarify prior communications about a pending application.
Court’s Ruling
Based on the summary of the law, the Appellate Division found that the applicant promptly gave the County what it asked for-- namely, the Wells Fargo statements. Upon receipt, the County’s duty was to review the pending application and notify the applicant concerning what, if any, additional information was required to make an eligibility determination. The record showed that the County failed to do so. Instead, it denied the March 31 application and only then informed the applicant that his application was deficient.
It followed that DMAHS’s final administrative decision adopting the improper denial of the March 31 application was arbitrary, capricious, and unreasonable. The Appellate Division reversed DMAHS’s decision and sent the case back to the County, instructing the agency to reopen and process M.L.’s Medicaid application.
Final Thoughts
Though practitioners know it is often the exception, this case serves as a crucial reminder that government agencies must adhere to procedural fairness when assessing Medicaid applications. Applicants have a right to clear communication and a reasonable opportunity to provide necessary documentation. Furthermore, state agencies cannot deny benefits based on minor technicalities or failures in their own procedures.
For Medicaid applicants facing similar challenges, this ruling reinforces the importance of persistence and legal advocacy. If you or a loved one has been wrongfully denied Medicaid benefits, consider consulting with an experienced attorney to ensure your rights are protected.
by Jose D. Roman | Feb 20, 2025 | Legal Bulletin, Medicaid
Public health advocates applauded the Court’s decision in D.C. v. Division of Medical Assistance & Health Services, 464 N.J. Super. 343 (App. Div. 2020), because it resolved a longstanding logistical issue that caused severe hardship for people transitioning from one Medicaid program to another. Specifically, the New Jersey Appellate Division ruled that state Medicaid agencies must screen beneficiaries for eligibility in alternative programs before terminating their existing benefits, ensuring a seamless transition and continuous benefits. Despite the Court’s clear mandate, over four years later, New Jersey has repeatedly failed to implement an effective “screen before terminate” system, leaving many vulnerable individuals exposed to gaps in coverage and financial hardship. Let’s revisit the case.
Factual Background
A married couple receiving Social Security Disability benefits were enrolled in New Jersey’s Aged, Blind, and Disabled (ABD) Medicaid Program. The program provides Medicaid health coverage for people with limited income who are blind, have been determined disabled by the Social Security Administration, or are 65 and over. However, following a change in circumstances the couple’s income exceeded the limit ABD eligibility. As a result, the Essex County Board of Social Services sent them a letter indicating that their ABD coverage would terminate effective August 31, 2017. Although they no longer qualified for ABD Medicaid, the couple still qualified for the Specified Low-Income Medicare Beneficiaries (SLMB) Program, which covers Medicare Part B premiums for low-income Medicare beneficiaries. The couple applied for the SLMB Program on August 30, 2017. Although they clearly qualified, the Essex County explained that their application could not be processed until their ABD benefits were officially terminated, which caused a gap in benefits. They filed for a Fair Hearing before an Administrative Law Judge who concluded that since benefits could be applied retroactively for 90 days, the state could terminate benefits without first assessing eligibility for other programs. The ALJ’s decision was adopted by the Division of Medical Assistance & Health Services (DMAHS) and the matter was then appealed to the Superior Court, Appellate Division.
Appellate Division Decision
The couple argued that federal regulations, including provisions found at 42 CFR 435.916(f)(1), mandate that state agencies screen beneficiaries for eligibility in other Medicaid programs before terminating existing benefits. They contended that the Division of Medical Assistance and Health Services (DMAHS) failed to perform this pre-termination screening for the SLMB Program, thereby causing a gap in benefits. DMAHS argued that the SLMB Program was “a Medicare savings program that allows states to pay Medicare Part B premiums,” rather than a Medicaid program, and since beneficiaries cannot be eligible for Medicaid and SLMB in the same month, they had to wait until coverage was terminated before applying. They argued that the requirement to screen for other programs prior to termination did not apply because SLMB was not a Medicaid program.
Importantly, the ALJ and DMAHS relied heavily on the 90 day retroactivity of New Jersey Medicaid to justify forcing people to have a disruptive gap in benefits, rather than implement a more efficient system. Under these rules, SLMB benefits could be applied retroactively for up to three months. The agency’s rationale was that even if there was a gap in immediate coverage, the retroactive provisions would compensate for the period during which the petitioners were without benefits. However, the couple argued that this reasoning did not absolve the agency of its responsibility to ensure a seamless transition in coverage. They also noted that the gap created a hardship because they had current obligations such as rent, food, and utilities.
The court found that SLMB was clearly a Medicaid program and that DMAHS erred by not screening the couple for eligibility in the SLMB Program before terminating their ABD benefits. The court held that relying on retroactive benefits subverted the purpose of pre-termination screening and did not justify a policy that permitted gaps in essential healthcare coverage. The court held that this was a circumstance where DMAHS acted in a way that was clearly inconsistent with its statutory mission and legislative policy. The court concluded that DMAHS’s decision was arbitrary, unreasonable, and erroneous, and therefore subject to being overturned. The decision was clear: DMAHS was required to proactively assess eligibility for other programs to prevent the disruption of benefits.
Current Challenges - County-Level Variability
In New Jersey, a significant portion of Medicaid eligibility decisions are handled by county-level agencies. As a result, compliance with the pre-termination screening requirement varies considerably from one county to another. Limited resources, inexperienced staff, and clerical errors lead to inconsistent application of the screening mandate. Instead of proactively transferring eligible beneficiaries between various Medicaid programs—such as SSI Medicaid, NJ Family Care/MAGI Medicaid, ABD Medicaid, MLTSS Medicaid, Workability Medicaid, and SLMB—the county offices often merely provide a referral or a new application and leave beneficiaries to navigate the system on their own.
Despite the clear mandate from the court, DMAHS has yet to develop and implement a robust, statewide system for conducting the required pre-termination eligibility screening and facilitating seamless transitions between programs. In practice, many beneficiaries continue to experience gaps in coverage because DMAHS appears to lack an integrated, automated system that cross-references a beneficiary’s eligibility for other Medicaid programs prior to terminating existing benefits. This means that the court’s requirement is not uniformly applied, leaving beneficiaries vulnerable to disruptions in care.
These challenges underscore the need for DMAHS and county agencies to collaborate on developing a comprehensive, statewide protocol. Or perhaps eliminate the county system altogether. Such a system should not only automate the screening process but also establish clear guidelines and accountability measures to ensure that beneficiaries do not experience unnecessary interruptions in their Medicaid benefits.
Final Thoughts
The ruling in D.C. v. Division of Medical Assistance & Health Services emphasizes the critical need for proactive administrative practices in the management of Medicaid benefits. By failing to pre-screen for eligibility in alternative programs, DMAHS not only violated federal regulatory requirements but also jeopardized the well-being of vulnerable low income people. Moreover, the lack of a cohesive, state-wide system to implement this requirement further compounds the problem, resulting in inconsistent and often inadequate protections for those most in need. This case just one example highlighting the need to reexamine and overhaul Medicaid administrative processes.
by Jose D. Roman | Feb 12, 2025 | Estate Planning, Legal Bulletin, Power of Attorney
Recently it was reported that an Asbury Park resident was detained by ICE after dropping his child off at school. Situations like this raise the question of who will care for the child if the parent remains in custody or is deported. Will someone be appointed guardian? Navigating New Jersey’s guardianship laws can be daunting, especially when a parent is temporarily unable to care for their child. Fortunately, N.J.S.A. 3B:12-39 provides a practical, court-free solution: it allows parents and legal guardians to delegate parental authority through a properly executed Power of Attorney. This flexibility is a lifeline for families, particularly immigrant parents who face the ever-present risk of detention, removal, or deportation in today’s unpredictable socio-political climate.
A Modern Solution for Modern Challenges
Under N.J.S.A. 3B:12-39, parents, custodians, or guardians can delegate their authority over a minor child’s care, custody, or property to a trusted individual. The delegation can take effect immediately or upon the occurrence of a specific “activating event.” The statute explicitly identifies several such events, including:
- A determination by the parent’s, custodian’s, or guardian’s attending physician that they are incapacitated or debilitated.
- Immigration administrative action, such as detention, removal, or deportation, which may separate a parent from their child.
- Criminal proceedings.
- Military service.
This streamlined process empowers families to plan ahead, avoiding the delays, costs, and complexities of court-appointed guardianship.
Why This Law is a Game-Changer for Immigrant Families
For immigrant parents, the fear of sudden detention or deportation can cast a long shadow over their ability to care for their children. In a political landscape where immigration policies are constantly in flux, this law provides a critical safety net. By including “immigration administrative action” as an activating event, N.J.S.A. 3B:12-39 directly addresses the unique challenges immigrant families face, offering several key advantages:
- Proactive Planning: Parents can execute a Power of Attorney in advance, designating a trusted individual to step in if an immigration action occurs.
- Avoiding Traumatic Placements: With a delegation in place, children are less likely to end up in temporary group settings and can remain with someone the family knows and trusts.
- Preserving Parental Rights: Even after delegating authority, parents retain the right to revoke the Power of Attorney or resume decision-making when circumstances allow.
- Peace of Mind: Knowing that a legal framework exists to protect their children allows immigrant parents to face their challenges with greater confidence.
This legal tool ensures that children continue to receive the care and stability they deserve, even in the face of immigration-related disruptions.
Practical Steps for Parents and Guardians
If you’re considering delegating parental authority under N.J.S.A. 3B:12-39, here are some key steps to keep in mind:
- Free Forms v. Paying a Lawyer: While it is always best to consult an experienced lawyer, there are free forms available. In fact, the text of the law itself actually provides a form you can use. If you can’t afford an attorney you should stick with the language from N.J.S.A. 3B:12-39 or use forms published by trusted sources such as local law school legal clinics or government websites. Here is a form from Rutgers Law School, along with an FAQ to answer common questions. Here is a form published by the New Jersey Department of Children and Families.
- Tailor the Power of Attorney: The document should clearly outline the scope of delegated powers and specify which activating events will trigger the delegation (including immigration-related issues).
- Address Consent Requirements: Obtain the consent of both parents or explain why the other parent is unable to provide consent (deceased, incapacitated, whereabouts unknown, etc.). This is outlined in the law and should be addressed in the form.
- Execute Properly: New Jersey requires a Power of Attorney to be notarized. However, it is recommended that you execute the document before two witnesses and a notary.
- Understand Renewal and Revocation: Be aware that the delegation expires after one year (with possible extensions under exigent circumstances). It can also be revoked by you at any time.
By taking these steps, parents can create a safety net for their families, ensuring stability even in the most uncertain times.
Final Thoughts
The Minor/Parental Power of Attorney under N.J.S.A. 3B:12-39 is a testament to New Jersey’s commitment to protecting families in crisis. By allowing parents to delegate parental authority without court intervention, the law provides a practical, compassionate solution for families facing emergencies. For immigrant parents, who often bear the brunt of shifting immigration policies, this legal mechanism is more than just a tool—it’s a vital safeguard for their children’s well-being.
by Jose D. Roman | Feb 4, 2025 | Legal Bulletin, Medicaid
In an interesting case from last year, J.R. v. Horizon NJ Health, A-2028-21 (February 5, 2024), the American Civil Liberties Union (ACLU) of New Jersey, supported by advocacy groups like Disability Rights New Jersey and the National Health Law Program, took on a widespread issue affecting Medicaid recipients. The case centered on J.R., a child with medically complex needs whose Private Duty Nursing (PDN) hours were significantly reduced by Horizon NJ Health, her Medicaid provider. Despite some clever legal arguments, the Superior Court of New Jersey, Appellate Division, ruled in favor of the Horizon’s decision to scale back J.R.’s care hours.
Background
Born prematurely in February 2019, J.R. faces serious medical conditions, including bronchopulmonary dysplasia, hypertension, and laryngomalacia. Initially, Horizon provided her with round-the-clock PDN care to meet her intensive medical needs. However, in 2020, Horizon reassessed her condition using a form called the PDN Acuity Tool—developed by Milliman Care Guidelines—and decided to cut her nursing hours from 24 per day down to just 8. This drastic reduction, which unfortunately is a common practice, was challenged. Specifically, at issue was the fairness and reliability of the process when using an automated assessment method such as the PDN Acuity Tool.
Legal Arguments: A Fight for Fairness
The ACLU of New Jersey, advocating for J.R., presented novel arguments against Horizon NJ Health’s decision, emphasizing the following concerns:
- Inadequate Notice: J.R.’s legal team argued that Horizon NJ Health failed to provide a clear, detailed explanation for reducing her PDN hours, leaving insufficient regulatory grounding for the decision.
- Questionable Standards and the PDN Acuity Tool: Critics contend that the reliance on the PDN Acuity Tool constitutes an overly opaque method for determining medical necessity. While automated tools can standardize assessments, such systems risk oversimplifying the complexities inherent with severe disabilities. The proprietary nature of the tool—and the lack of transparency regarding its underlying algorithms—can conceal potential biases and errors that adversely affect vulnerable populations.
- Ignoring Medical Expertise: Despite J.R.’s treating physician’s strong recommendation for 24/7 care, the decision-making process largely depended on the tool’s point score, which may not fully incorporate individualized clinical judgments.
The PDN Acuity Tool and Automated Decision-Making
This case is an important attempt at taking a critical look at the implications of using automated decision-making systems in the delivery of healthcare:
- Balancing Standardization and Individual Needs: The PDN Acuity Tool was designed to convert complex clinical data into a quantifiable score. However, this case highlights the fact that while such tools promote consistency, they may fall short when addressing the multifaceted nature of a patient care. In J.R.’s case, the tool’s reduction from 24 to 8 hours was based on a standardized scoring system that her attorneys argued failed to fully capture the child’s nuanced clinical needs, and was contrary to the recommendation of her physician.
- Transparency and Accountability Concerns: Critics argue that using algorithmic forms such as the PDN Acuity Tool lack transparency because there is no clear disclosure of how individual variables are weighted. The forms simply have pre-determined point values without disclosing how the point value was determined. As a result, consumers are left with little means to challenge potentially arbitrary reductions in care. This analysis underscores the necessity for state agencies to ensure that automated assessments are accompanied by detailed, accessible explanations that uphold due process rights. It also highlights a roadmap for future legal challenges.
- Impact on Individuals with Unique Needs: While automated decision-making systems may be efficient, they may inadvertently disadvantage those with complex or atypical care needs. The legal discourse around J.R.’s case illustrates how reliance on proprietary tools can obscure critical nuances and lead to decisions that appear “reasonable” on paper but are ethically problematic when applied to individual patients.
The Court’s Decision: A Disappointing Outcome
The Appellate Division ultimately upheld the decision to reduce J.R.’s care hours, concluding that Horizon NJ Health had acted within Medicaid regulations. The ruling was based on several key points:
- Sufficient Notice: The court found that, despite lacking explicit regulatory citations, the notice provided adequate information about the reasons for the reduction.
- Legitimacy of the PDN Acuity Tool: No evidence was presented showing improper use of the tool. The court accepted its results as a “reasonable and objective” method to determine medical necessity, even as critics warned that such assessments might not fully address individual clinical complexities.
- Consideration of Medical Evidence: The review included extensive clinical records and expert testimony, which the court deemed sufficient to support the decision.
What This Means for Medicaid Recipients
J.R.’s case brings to light the ongoing tension between cost containment measures and the rights of Medicaid beneficiaries to receive personalized, medically appropriate care. While automated tools like the PDN Acuity Tool offer efficiency, they also underscore the need for transparency, individualized assessment, and robust safeguards against the potential biases inherent in algorithm-driven decisions.
Looking Ahead
Although the ruling was not favorable, it highlights an important conversation regarding the use of automated decision-making systems. The Appellate Division seemed to indicate that it was looking for more evidence from J.R.’s side that could be a roadmap for future litigation. Specifically, the court noted that at the hearing stage “J.R. had the right to discovery, to subpoena witnesses, and to call her own witnesses, including experts.” Perhaps depositions of Horizon representatives and experts, as well as testimony from experts who are critical of the PDN tool could change the outcome in a future case. In the meantime, advocacy organizations will continue to call for clearer guidelines, enhanced transparency, and more comprehensive evaluations that integrate both standardized assessments and individualized clinical judgments. This case serves as a powerful reminder of the critical role legal advocacy plays in ensuring that technological advancements in healthcare do not come at the expense of patient rights and quality care.