Fighting Back Against Arbitrary Medicaid Denials for Failure to Respond
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.
