Appealing the Denial of a Medicaid

Application in New Jersey

Fair Hearing Appeals in New Jersey

Fredrick P. Niemann, Esq., a NJ

Appeal of Medicaid Denial Attorney

The filing and processing of a Medicaid application can be frustrating.   After assembling five (5) years worth of financial information and doing everything reasonably requested by the State to achieve eligibility, many applicants and/or their representatives are frustrated by the continual delays and/or demands for additional information.  Often the applicant or their representative is unable to reach the case worker assigned to the application in order to obtain a status update or assistance when questions pertaining to the application come up.  If this is your experience, you are not alone.

The blame does not lie with the employees of the County Board of Social Services, rather the blame belongs to a system which is designed to frustrate, delay and then deny applications for New Jersey Medicaid.  New Jersey has made a calculated gamble that if they make the application process hard enough people will either walk away or delay their compliance, thus saving the State the funds necessary to provide long term care for its elderly residents.  However, you have rights!

HOW DO YOU APPEAL A DENIAL OF MEDICAID

ELIGIBILITY IN NEW JERSEY?

If the County Board of Social Services fails or refuses to process your application within the mandated 30/45 review period, you are entitled to file an appeal.   Further, if your application is denied for any reason whatsoever or the manner in which the application is being processed is unlawful, you have the right to file an appeal.   This appeal is called a Fair Hearing Appeal.  Fair Hearing Appeals in NJ have to be filed within twenty (20) days of a denial or other official action taken by the County Board of Social Services.

A Fair Hearing Appeal is against your County Board of Social Services, the administrative agent of New Jersey Medicaid.   It is a proceeding against the county which affords you an opportunity to present your case before a New Jersey Administrative Law Judge.  An Administrative Law Judge is a quasi judicial official who is an attorney by education and training and who has achieved the status of Administrative Law Judge by appointment from the Governor.  An Administrative Law Judge hears the evidence and makes a decision on the merits of your appeal.  Like any quasi-judicial proceeding the burden of proof is upon you to prove your case.  This means that you must produce direct evidence by testimony, documents and information which is relevant to the reasons why the appeal was taken.  The case is often heard in an informal setting by a single judge and unlike the TV shows you may be familiar with, there is no jury or other sophisticated courtroom accessories. The appeal setting consists of the Judge, representatives of the county and you, each producing evidence to create a record which is maintained in audio form.

To be successful you must be prepared. Generally, Fair Hearing appeals should be undertaken with the assistance of legal counsel who is experienced in Courtroom cases and litigation otherwise you may fail to file the correct papers, follow required procedural rules and/or produce the necessary evidence to win.

If you have questions concerning your rights to file a Fair Hearing Appeal in New Jersey or want a legal opinion on the likelihood of your success, contact Fredrick P. Niemann, Esq., an experienced New Jersey Fair Hearing Appeal of Medicaid Denial Attorney at 3499 Route 9 North, Suite 1-F, Freehold, New Jersey 07728, or email him at fniemann@hnlawfirm.com; you can call him toll free at (855) 376-5291.

What Is the Legal Effect of an Administrative Law Decision on your New Jersey Medicaid Application?

An Administrative Law Judge is able to reverse a denial of eligibility by the County Board of Social Services and/or other adverse decisions made by the County.   Unfortunately this does not necessarily end the matter.   By law, the Director of New Jersey Medicaid has forty five (45) days to either uphold, modify or reverse the decision of the Administrative Law Judge.  This means that while you may win before the Administrative Law Judge, the Director of New Jersey Medicaid has the authority to reverse the decision in full or in part.  If this happens you still have rights.   You have the right to appeal the Director’s decision to the Appellate Division of the New Jersey Superior Court.  This appeal is a matter of right and is decided by a three (3) Judge panel at the State Capitol in Trenton, New Jersey.   The Appellate Division will review the evidence, testimony and documents submitted before the Administrative Law Judge and will evaluate whether the Director’s decision is lawful or a violation of New Jersey Federal Medicaid Law.  

Often times, an appeal to the Appellate Division is necessary in order to reverse what is often times an incorrect and/or arbitrary decision by the Director.  And, unlike an Administrative Law Hearing, the Director of New Jersey Medicaid cannot override a decision by the New Jersey Superior Court. 

Final thoughts on Denial of a Medicaid Application

In this age of reduced public resources and New Jersey’s hostile environment towards Medicaid eligibility, it is important that you know your rights to Appeal.  Just because the County is hostile towards your application and/or denies your application, you have a legal right under federal law to appeal New Jersey and the County Board of Social Services.  One should have a denial of eligibility or other adverse decision reviewed by an experienced New Jersey Medicaid Law attorney familiar with the Medicaid process and receive a legal opinion on the likelihood of a successful appeal particularly when nursing home and assisted living care costs exceed $6,000 - $11,000 per month.

For more information on the law of NJ concerning discharge from a nursing home, assisted living residence, go to dischargefromnjnursinghome.com (click here).

You will find him knowledgeable in Medicaid eligibility law, sensitive, and easy to talk to.  Mr. Niemann has tried many cases before juries, Superior Court Judges, the New Jersey Appellate Division of Superior Court, the Supreme Court of New Jersey as well as the U.S. District Court and the Third Circuit Court of Appeals.