G.C. v. Div. of Med. Assistance & Health Servs.

• Decision Date: 18 March 2020
• Docket Number: DOCKET NOS. A-0772-18T3,A-1935-18T3
• Citation: 229 A.3d 551,463 N.J.Super. 79
• Parties: G.C., Petitioner-Appellant, v. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES, Respondent-Respondent, and Ocean County Board of Social Services, Respondent. E.M., Petitioner-Appellant, v. Division of Medical Assistance and Health Services and Essex County Board of Social Services. Respondents-Respondents.
• Court: New Jersey Superior Court — Appellate Division

463 N.J.Super. 79

229 A.3d 551

G.C., Petitioner-Appellant,

v.DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES, Respondent-Respondent,andOcean County Board of Social Services, Respondent.

E.M., Petitioner-Appellant,

v.Division of Medical Assistance and Health Services and Essex County Board of Social Services. Respondents-Respondents.

DOCKET NOS. A-0772-18T3

A-1935-18T3

Superior Court of New Jersey, Appellate Division.

Argued January 13, 2020

Decided March 18, 2020

Thomas John La Maina, Cherry Hill, argued the cause for appellant G.C. (South Jersey Legal Services, attorneys; Kenneth Mark Goldman, Atlantic City, and Jakai T. Jackson, on the briefs).

Joshua M. Spielberg argued the cause for appellant E.M. (Legal Services of New Jersey, attorneys; Joshua M. Spielberg and Kristine Marietti Byrnes, on the briefs).

Shereen R. Youssef and Francis Xavier Baker, Deputy Attorneys General, argued the cause for respondent Division of Medical Assistance and Health Services in A-0772-18 and A-1935-18 (Gurbir S. Grewal, Attorney General, attorney; Melissa H. Raksa, Assistant Attorney General, of counsel; Shereen R. Youssef and Francis Xavier Baker, on the briefs).

Courtney M. Gaccione, Essex County Counsel, attorney for respondent Essex County Board of Social Services, join in the brief of respondent Division of Medical Assistance and Health Services.

Before Judges Messano, Vernoia and Susswein.

The opinion of the court was delivered by

MESSANO, P.J.A.D.

We issue a single opinion in these appeals, which were argued back-to-back, because the sole issue before us is whether a regulation promulgated by the Department of Human Services, Division of Medical Assistance and Health Services (the Division), setting a methodology to determine eligibility for benefits under NJ Medicaid — Aged, Blind, and Disabled Program (ABD), contravenes both the federal Medicaid statute, Title XIX of the Social Security Act, 42 U.S.C. §§ 1396 - 1396w-5 (Title XIX), and New Jersey's Medicaid statute, the "New Jersey Medical Assistance and Health Services Act[,]" N.J.S.A. 30:4D-1 to -19.5 (the Act). N.J.A.C. 10:72-4.4(d) explains those circumstances in which the income of certain family members of an aged, blind or disabled adult or child is "deemed," or attributed, to the applicant. Regardless whether any income is "deemed" or not, the regulation provides that "[i]f the countable income (before income deeming) of the aged, blind, or disabled individual exceeds the poverty income guideline for one person he or she is ineligible for benefits and income deeming does not apply." N.J.A.C. 10:72-4.4(d)(1) (the Regulation) (emphasis added).

G.C. and E.M. are both disabled and applied for ABD Medicaid benefits. At the time of her application, G.C. was fifty-years old, lived with her husband, also fifty and unemployed, and their two children, ages fourteen and twelve. G.C.'s sole income was $1141 per month from Social Security Disability (SSD) benefits.¹ Each of the children received $279.90 per month in Social Security benefits as G.C.'s dependents. Thus, the family's total monthly income was $1700.80.

E.M. was fifty-seven-years old and resided with his wife, who was fifty-three and did not work. E.M.'s sole income was $1193 per month in SSD benefits.²

The respective county boards of social services denied both applications. Each board applied the Regulation's methodology and concluded that G.C.'s and E.M.'s countable income exceeded the monthly federal poverty level (FPL) at the time for one person — $1005 — and, therefore, both were ineligible for ABD benefits. See N.J.A.C. 10:71-5.6(a) (setting income eligibility standards for the ABD program). For our purposes, all parties agree that G.C.'s and E.M.'s countable incomes fall below the FPL for a family of four or two respectively, and, if those income limits applied, both would qualify for benefits.

G.C. and E.M. appealed to the Division, which transferred the cases to the Office of Administrative Law as contested matters. In G.C.'s case, the administrative law judge (ALJ) found she was ineligible because her individual "countable income" exceeded the FPL guideline for one person. The Division accepted and affirmed the findings and conclusions of the ALJ and denied G.C.'s application. In E.M.'s case, the ALJ concluded that the Regulation contravened 42 U.S.C. § 1396a(m), and N.J.S.A. 30:4D-3(i)(11), because both statutes require that family size be considered in determining eligibility for ABD benefits. The Division rejected the ALJ's conclusion and, in its final agency decision, applied the Regulation, concluded E.M.'s "countable" income exceeded the FPL for one person, and denied his application.

These appeals followed.

I.

We provide some necessary background on Medicaid, and the statutory and regulatory regime adopted in New Jersey. As a joint program between the federal government and those states that choose to participate, Medicaid provides medical assistance to needy persons at public expense. N.E. v. N.J. Div. of Med. Assistance & Health Servs., 399 N.J. Super. 566, 571, 945 A.2d 109 (App. Div. 2008). Participating states are required to comply with Title XIX and its implementing regulations, E.B. v. Div. of Med. Assistance & Health Servs., 431 N.J. Super. 183, 191, 67 A.3d 671 (App. Div. 2013) (citing United Hosps. Med. Ctr. v. State, 349 N.J. Super. 1, 4, 793 A.2d 1, (App. Div. 2002) ), including "eligibility requirements set by the federal government[,]" Zahner v. Sec'y Pa. Dep't of Human Servs., 802 F.3d 497, 512 (3d Cir. 2015). "Each participating state must adopt a plan that ‘includes "reasonable standards ... for determining eligibility for ... medical assistance ... [that is] consistent with the objectives" of the Medicaid program.’ " Mistrick v. Div. of Med. Assistance & Health Servs., 154 N.J. 158, 166, 712 A.2d 188 (1998) (alteration in original) (quoting L.M. v. Div. of Med. Assistance & Health Servs., 140 N.J. 480, 484–85, 659 A.2d 450 (1995) ).

"States that participate in the Medicaid program must provide coverage to the ‘categorically needy,’ which includes[, among others,] persons eligible to receive benefits under Aid to Families with Dependent Children (AFDC), or [SSI] for the Aged, Blind, and Disabled under Title XVI of the Social Security Act ...." L.M., 140 N.J. at 485, 659 A.2d 450 (citations omitted) (citing 42 U.S.C. § 1396a(a)(10)(A)(i) ). "The categorically needy are ‘persons whom Congress considered especially deserving of public assistance because of family circumstances, age, or disability.’ " Ibid. (quoting Schweiker v. Gray Panthers, 453 U.S. 34, 37, 101 S.Ct. 2633, 69 L.Ed.2d 460 (1981) ).

States may opt to provide coverage to other groups of individuals, including the "optional categorically needy[,]" ibid. (quoting Herweg v. Ray, 455 U.S. 265, 268–69, 102 S.Ct. 1059, 71 L.Ed.2d 137 (1982) ), those categories of individuals defined in 42 U.S.C. § 1396a(a)(10)(A)(ii).³ As the Second Circuit succinctly explained:

States participating in the Medicaid program are required to provide coverage to certain groups[ ] and are given the option to extend coverage to various other groups. The line between mandatory and optional coverage is primarily drawn in § 1396a(a) : mandatory coverage is specified in § 1396a(a)(10)(A)(i), and the state options are set forth in subsection (ii). The groups specified in these sections are collectively referred to ... as the "categorically needy."

[ Skandalis v. Rowe, 14 F.3d 173, 175–76 (2d Cir. 1994).]

Appellants are in the optional categorically needy group of putative benefit recipients. Pursuant to § 1396a(10)(A)(ii)(X), states may, but are not required, to provide Medicaid benefits to "any group ... of individuals described in [ 42 U.S.C. § 1396d(a) ]" who are not categorically needy under subsection (i), and "who are described in subsection (m)(1) ...." In turn, 42 U.S.C. § 1396d(a) includes those who are not receiving SSI benefits, but are, among other things, sixty-five-years old or older, blind, or permanently and totally disabled. 42 U.S.C. § 1396d(a)(iii) — (v). See also 42 CFR 435.201(a)(1) — (3) (allowing states to provide coverage to aged, blind and disabled "as optional categorically needy" individuals). Subsection (m)(1), entitled "Description of Individuals[,]" in turn includes disabled individuals. 42 U.S.C. 1396a(m)(1)(A). The methodology used by a state to determine "eligibility for optional categorically needy applicants may be less restrictive, but may not be more restrictive, than the methodology used to determine eligibility for SSI applicants." Mistrick, 154 N.J. at 168, 712 A.2d 188 (citing 42 U.S.C. § 1396a(r)(2)(A) ).

"The [Act] authorizes New Jersey's participation in the federal Medicaid program." E.B., 431 N.J. Super. at 192, 67 A.3d 671 (citation omitted). The program was expanded in 1988 to "include aged, blind, and disabled individuals not otherwise eligible" for New Jersey's Medicaid Only program as it then existed. A.B. v. Div. of Med. Assistance & Health Servs., 407 N.J. Super. 330, 345, 971 A.2d 403 (2009) (citing N.J.A.C. 10:71-1.1 to - 9.5 ). The Act defines a "qualified applicant" to include "an individual ... who is ... disabled ... whose income does not exceed 100% of the poverty level, adjusted for family size[.]" N.J.S.A. 30:4D-3(i)(11) (emphasis added).

The provisions of Title XIX regarding eligibility are considerably more obtuse, requiring a roadmap and compass to navigate. First, 42 U.S.C. § 1396a(a)(10)(C) provides that if a state chooses to provide medical assistance

for any group of individuals described in section [ 42 U.S.C. § 1396d(a) ] ... who are not described in [ § 1396a(a)(10)(A) ] ... then — (i) the plan must include a description of ... (III) the single standard to be employed in determining income ... eligibility for all such groups, and the methodology to be employed in determining such eligibility, which shall be no more restrictive than the methodology which would be employed under the [SSI]

...