- Federal and NJ laws and regulations allow an applicant to appeal denial of Medicaid nursing home and assisted living benefits.
- A fair hearing appeal before an Administrative Law Judge allows an applicant to challenge the state’s decision to deny Medicaid long term care benefit.
- An executor for the Estate of a Medicaid applicant who dies during the application process has the right to appeal a denial through its Estate representation.
Federal Law Allows Medicaid Denial Appeals
Under applicable state and federal regulations, if an “applicant” is denied Medicaid benefits, the “applicant is given the opportunity for a fair hearing appeal under the policies and procedures set forth in N.J.A.C. 10:49-10 and 10:69-6.” Pursuant to N.J.A.C. 10:71-8(a) applicants have the right to fair hearings when “their claims are denied or are not acted upon with reasonable promptness”. Requests for fair hearings must be submitted to DMAHS (the state medical office) in writing within twenty days of a denial, reduction, or partial denial of Medicaid benefits.
State Court Reverses New Jersey’s Attempt to Dismiss a Fair Hearing Appeal
According to case law, a fair hearing can only be denied if “the applicant withdraws the request in writing, or if the applicant fails to appear at a scheduled hearing without good cause.”
The Superior Court of N.J. interpreted DMAHS’s argument that it refused to schedule a fair hearing because the Estate’s Executor was “an unauthorized third party,” and therefore did not have standing, or right to request a hearing, as N.J.A.C. 10:71-8.4 permits fair hearings only for an “applicant”. The court concluded that DMAHS must transfer the case to the office of Administrative Law to address the standing claim, and if standing is allowed, the merits of the dispute must be decided by the court.
The purpose of a fair hearing is to permit the State to exercise its “special competence” and address whether an applicant is entitled to benefits. The fact that the applicant died pending the decision on its application does not deprive his or her Estate from appealing a subsequent denial.
To discuss your NJ Medicaid Denial Appeal matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at firstname.lastname@example.org. Please ask us about our video conferencing consultations if you are unable to come to our office.
By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold Township, Monmouth County, NJ Appeal of Medicaid Denial Attorney