Sandoval v. Shah

Proceeding pursuant to CPLR article 78 to review a determination of a designee of the Commissioner of the New York State Department of Health dated August 13, 2013, which, after a fair hearing, affirmed a determination of the Putnam County Department of Social Services that the petitioner was not eligible for Medicaid assistance for a period of approximately 11 months and imposed an additional partial month penalty due to a transfer of certain of the petitioner’s assets for less than fair market value.

Adjudged that the petition is granted, on the law, with costs, the determination is annulled, the respondents are directed to provide the petitioner with retroactive Medicaid benefits for a period of approximately 11 months, and the matter is remitted to the respondent Commissioner of the New York State Department of Health for a calculation of the amount of retroactive benefits due and owing and for the payment immediately thereafter to the petitioner.

In reviewing a Medicaid eligibility determination made after a fair hearing, the court must review the record as a whole to determine if the agency’s decisions are supported by substantial evidence and are not affected by an error of law (see Matter of Rivera v Blass, 127 AD3d 759 [2015]). Substantial evidence has been defined as “such relevant proof as a reasonable mind may accept as adequate to support a conclusion or ultimate fact” (300 Gramatan Ave. Assoc. v State Div. of Human Rights, 45 NY2d 176 , 180 [1978]). While the level of proof is less than a preponderance of the evidence, substantial evidence does not arise from bare surmise, conjecture, speculation, or rumor (see id. at 180 ), or from the absence of evidence supporting a contrary conclusion (see Matter of Harrison v Palumbo, 122 AD3d 634 , 635 [2014]). When determining Medicaid eligibility, an agency is required to “look back” for a period of 60 months immediately preceding the first date the applicant was both “institutionalized” and had applied for Medicaid benefits to determine if any asset transfers were uncompensated or made for less than fair market value (42 USC § 1396p [c] [1] [A], [B]; Social Services Law § 366 [5] [e] [1] [vi]). If such a transfer was

Here, the evidence at the fair hearing showed that the latest of the subject transfers was made approximately two years before the petitioner started to exhibit signs of dementia. At the time of the transfers and in the years preceding her need for nursing home care, the petitioner was in good health and living independently. She was driving, cooking, exercising, and paying her own bills. The transfers themselves constituted gifts to her relatives, and the petitioner still had more than $250,000, not including Social Security benefits, following the transfers. Under these circumstances, the petitioner met her burden of rebutting the presumption that the subject transfers were motivated by the anticipation of a future need to qualify for medical assistance (see Matter of Safran v Shah, 119 AD3d 590 , 591 [2014]; Albert v Perales, 156 AD2d 619 [1989]; cf. Matter of Carter v Brandwein, 182 AD2d 620 [1992]). As those transfers do not render the petitioner ineligible for Medicaid benefits, the determination of the DOH is not supported by substantial evidence and, thus, must be annulled.

Dillon, J.P., Chambers, Austin and Sgroi, JJ., concur.