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Green Valley SNF, LLC v. Delaware Department of Health & Social Services

Superior Court of Delaware, Kent

December 31, 2013

GREEN VALLEY SNF, LLC d/b/a PINNACLE REHABILITATION and HEALTH CENTER, Appellant,
v.
DELAWARE DEPARTMENT OF HEALTH AND SOCIAL SERVICES, DIVISION OF MEDICAID and MEDICAL ASSISTANCE, Appellee.

Submitted: October 23, 2013

Upon Consideration of Appellant's Appeal from the Department of Health and Social Services

Margaret F. England, Esquire, The Darby Law Firm, LLC, Wilmington, Delaware for Appellant.

Peter S. Feliceangeli, Esquire, Deputy Attorney General, Department of Justice, Wilmington, Delaware for Appellee.

ORDER

Young, J.

SUMMARY

Green Valley SNF, LLC d/b/a Pinnacle Rehabilitation and Health Center ("Pinnacle") applied for long-term care Medicaid Benefits for Pauline Bryner ("Claimant"), a resident of the facility. The Department of Health and Social Services ("DHSS"), Division of Medicaid and Medical Assistance ("DMMA") denied the application, because Pinnacle did not provide the required information for DMMA to make a decision on the Claimant's eligibility for benefits. In an administrative "Fair Hearing" to challenge the decision, a DHSS Fair Hearing Officer affirmed the DMMA's decision to deny the application for benefits. Pinnacle has appealed this decision of the Hearing Officer. The primary issue on appeal is whether the DMMA correctly denied an application for long-term care Medicaid benefits, based upon a finding that Pinnacle failed to submit the information that the DMMA requested, in order to determine if the applicant met the financial eligibility requirements for benefits. As a result of the DHSS decision, a matter that could bring about dire consequences to Claimant was determined by what appears to be a reliance upon a non-jurisdictional timing concern, when facts on the merits were either known, but ignored, or else not pursued. For example, the DHSS reviewing caseworker failed to establish why the Claimant's real property was not being sold, though knowledge that the Claimant's Guardianship existed. Therefore, the decision of the DHSS Hearing Officer is REVERSED and REMANDED for a complete hearing on the merits of the claim for benefits.

FACTS AND PROCEDURAL POSTURE

On February 19, 2010, Claimant was admitted into Pinnacle, with diagnoses of Alzheimer's disease and dementia. Soon thereafter, Pinnacle sought to obtain a public guardian for the Claimant, but at the time the Office of the Public Guardian only took emergency cases. Pinnacle filed an application for Medicaid benefits for Claimant in July 2010, which was denied in September 2010, due to missing documentation.

Pinnacle was directed to file a second application on October 29, 2010, which was eventually denied on February 23, 2011. The second application was denied, because of the lack of verification regarding the resources of the Claimant, specifically regarding a piece of real property. The information that Pinnacle provided in the Medicaid application filed on October 29, 2010, listed 407 North New Street, Dover, as the Claimant's most recent address, but gave no indication about whether the Claimant owned or rented the property. Then, the DMMA sent Pinnacle a "We Need" letter on January 27, 2011, listing the information the agency needed before it could complete its determination of Claimant's financial eligibility. The DMMA requested the documents by February 11, 2011. The January 27, "We Need" letter cautioned that, if the DMMA did not receive the requested information by February 11, 2011, the DMMA would assume that the Claimant was no longer interested in the Medicaid program, and the application would be denied.

The DMMA asked for the following items to complete an eligibility determination related to Claimant's property: a copy of the deed, a completed and signed agreement to sell form, market analysis for the value of the property, and proof that the property was listed for sale. Pinnacle sent tax assessment records and liens of record as evidence of the fair market value, and submitted notice of a tax sale of the property as evidence that it was for sale. The DMMA did not consider notice of a forced sale to mean the property was on the market. The agency also informed Pinnacle that showing the assessed value was insufficient. Rather, Pinnacle needed to demonstrate the fair market value of the property.

The DMMA did not receive the requested information regarding the real property that it desired to make a decision on Claimant's eligibility for long-term Medicaid benefits by the due date, February 11, 2011. Pinnacle admitted that it did not check the public records, even for a copy of the deed, until after the application had been denied. In addition, Pinnacle did not request an extension of the time to submit the requested information about Claimant's property.

A caseworker for the DMMA was aware that the Claimant was incapacitated, and that a Guardianship action was pending in the Court of Chancery during the time the caseworker was reviewing the Claimant's Medicaid application. However, the application was still denied even though no party had authority to obtain the requested information that the DMMA requested. Subsequent to the denial on February 23, 2011, a Guardian was appointed for the Claimant on March 18, 2011. Thereafter, on April 28, 2011, a request for a Fair Hearing on said denial with the DHSS was made. The Fair Hearing was held on September 26, 2011. On October 20, 2011, the DHSS dismissed the action on the grounds that Pinnacle lacked standing to challenge the denial. That decision was appealed to this Court on May 1, 2012. On August 29, 2012, the Superior Court ...


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