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K.L v. Division of Medical Assistance and Health Services and Passaic County

March 9, 2012

K.L., PETITIONER-APPELLANT,
v.
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES AND PASSAIC COUNTY BOARD OF SOCIAL SERVICES, RESPONDENTS-RESPONDENTS.



On appeal the Division of Medical Assistance and Health Services, Docket No. 5328-10.

Per curiam.

RECORD IMPOUNDED

NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION

Argued February 27, 2012

Before Judges Sabatino and Fasciale.

Petitioner K.L., through his wife B.L., appeals from a final agency decision of the Division of Medical Assistance and Health Services (DMAHS) finding that B.L.'s monthly expenses do not rise to the level of exceptional circumstances warranting an increase in her minimum monthly maintenance needs allowance (MMMNA).*fn1 We affirm without prejudice to allow reconsideration of whether unreimbursed flood damages warrant an adjustment to the MMMNA.

In 2009, K.L. entered a nursing care facility and became eligible for Medicaid benefits. B.L. continued to reside in their marital home of fifty years. The Passaic County Board of Social Services (PCBOSS) determined that B.L. was entitled to receive $1,637.95 from K.L.'s monthly income. B.L. received that amount plus her own income of $660 per month, for a total MMMNA of $2,298.45. The nursing facility received $599.87 per month, the amount left over from K.L.'s income after B.L. received her share.

K.L. filed an administrative appeal contending that the amount of the MMMNA was insufficient to cover B.L.'s expenses related to medical and psychological costs, flood-repair costs, transportation costs, life insurance policy expenses, and attorney expenses. As a result, K.L. argued that based on these categories of expenses, there existed exceptional circumstances resulting in financial distress that warranted an increase in B.L.'s MMMNA. The DMAHS transmitted the matter to the Office of Administrative Law for a hearing before an administrative law judge (ALJ).

The ALJ conducted a nonconsecutive two-day hearing and issued an eleven-page written opinion dated December 10, 2010. The ALJ found:

[K.L.] has submitted proof of exceptional circumstances that require expenditure of funds by [B.L.] for: medical and psychological services, health insurance, and pharmacy bills - $370.80 monthly, shelter expenses - $1,867.41 averaged monthly, transportation - $178.00 monthly, other costs for food, clothes, internet, phone, newspaper, life insurance, legal fees, beauty and hygiene costs - $1,112.38 monthly, and all totaling $3,528.59[.] [B.L.'s] expenses exceed the spousal allowance by $1,890.64[.] . . . . [B.L.] is experiencing exceptional and extraordinary circumstances, which are causing physical stress, financial duress, and a current hardship.

The ALJ then ordered that the community spouse monthly income allowance, a component of the MMMNA, be "increased to allow [B.L.] to retain all of the resources available at the time

[K.L] applied for Medicaid benefits in 2009." The ALJ also ordered that the PCBOSS recalculate resources when the flood-repair costs and attorney fees are paid.

The PCBOSS appealed from the ALJ's initial decision, and the Director of the DMAHS (the Director) conducted an independent review of the record and issued a five-page final agency decision. On January 20, 2011, the Director concluded that K.L. did not demonstrate exceptional circumstances resulting in financial duress, determined that there was no basis to increase B.L.'s MMMNA, and reversed the initial decision of the ALJ. This appeal followed.

On appeal, B.L. argues that the Director's final agency opinion was arbitrary and violated her property rights to marital support and the legislative policies of avoidance of spousal impoverishment. She argues that the Director ignored factual evidence and ...


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