Oct 2

Medicaid Director Needs to Hold Full Hearing on Facts Before Ruling Against Recipient


A New Jersey appeals court rules that a state Medicaid director could not rule against an assisted living facility resident who wanted to deduct the cost of a full-time aide from her income because the administrative law judge (ALJ) did not hold a full evidentiary hearing on whether the aide was medically necessary. G.F. v. Division of Medical Assistance and Health Services (N.J. Super. Ct., App. Div., No. A-3067-16T3, Sept. 12, 2018).

Assisted living resident G.F. received Medicaid benefits that required her to contribute some of her income to her care. She claimed a full-time aide was medically necessary to keep her from falling, and she asked to deduct the cost of the aide from her income. The state denied the request, and G.F. appealed.

In filings with the ALJ, the state did not dispute that the aide was medically necessary. Instead, the state argued that G.F. needed to be in a nursing home. The ALJ determined that there was no dispute as to facts, so it ruled for G.F. without an evidentiary hearing. The state Medicaid director ruled that because G.F.'s doctor did not testify at the hearing, G.F. did not prove that the aide was medically necessary and reversed the ALJ's decision. G.F. appealed to court.

The New Jersey Superior Court, Appellate Division, remands the state's decision for a full hearing on whether the aide is medically necessary. According to the court, while the director correctly determined that G.F. did not prove the aide was medically necessary, G.F. "did not present live testimony to support her claim because the parties agreed there was no need to do so, and the ALJ determined the matter could be decided on the papers."

For the full text of this decision, go to: https://www.njcourts.gov/attorneys/assets/opinions/appellate/unpublished/a3067-16.pdf?cacheID=Uga2KPl