• A Medicaid Fair Hearing is a legal challenge to a decision by a County Board of Social Services (CBOSS) concerning any issue related to Medicaid eligibility (or a lack of Medicaid eligibility).
• The hearing is conducted before an administrative law judge (“ALF) at the New Jersey Office of Administrative Law (“OAL”).
• The ALJ issues his or her Initial Decision with findings of fact and conclusions of law. Thereafter, the Agency Head — DMAHS — has 45 days in which to either accept, reject, or modify the Initial Decision.

The Office of Administrative Law (OAL) has jurisdiction over all contested cases.  A “contested case” is defined as “an adversary proceeding, … in which the legal rights, duties, obligations, privileges, benefits or other legal relations of specific parties are decided by an agency after an agency hearing.”

Pre-Hearing Conference

Preparation for a fair hearing appeal is a key to success.  At Hanlon Niemann & Wright, we approach an appeal the way we prepare for a trial.  It is important to be familiar with all of the facts and legal issues involved in the Medicaid application so we are able to cite to the state Medicaid manual and/or the applicable federal Medicaid statute(s), regulation(s) and case law to substantiate our argument.

Pre-Hearing Discovery

All appellants have the right to discovery about their case and their appeal.  We conduct discovery through interrogatories and demand for admissions.

We often times seek an in-person examination of the county’s file.  Under federal and state law, a Medicaid applicant (or her attorney) has the right to examine the entire Medicaid file in advance of the Fair Hearing. N.J.A.C. 1:10B-10.1. The Agency “shall provide” “an opportunity to review the entire case file and all documents and records to be used in the hearing. The review shall occur at a reasonable time before the hearing as well as during the hearing.”

A file review can provide a wealth of information regarding the Medicaid application in question and the practices and procedures of the county welfare office in general, that are not otherwise available. It is not unusual to find notes and e-mails and documents which could support your position that the agency’s action was arbitrary and capricious (these are legal words that basically mean the county denied you for no good reason).

Federal law allows not only a review of the file, but the ability of an appellant (even pro-se) to use the materials found in the file.

Burden of Proof to Win Your Appeal

The burden to prove Medicaid eligibility rests on an appellant.  “as in all welfare eligibility determinations, the Medicaid applicant bears the burden of establishing program eligibility by a preponderance of the credible evidence.”  Preponderance of evidence can also be described as the greater weight of credible evidence having a greater convincing power.

To discuss your NJ Appeal of Medicaid Denial matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com.  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