The notice from the state Department of Human Services came last month with no warning. It was marked “final agency decision."

The five-page document said the number of hours Anna Landre’s health insurance company would pay for home health aides to help her dress, go to the bathroom, cook and take care of herself in her campus apartment would be slashed from 16 hours to 10 hours each day.

Landre, a New Jersey college student who uses a motorized wheelchair, knew the bluntly-worded document meant one thing: She’d have to drop out of Georgetown University.

Like many college students with severe disabilities, Landre’s choice to live away at college involved a complex web of home health aides, Medicaid money, health insurance approvals and other accommodations that can disappear at any moment.

“I think disabled people exist in a constant state of stress. We are always waiting for the other shoe to drop,” said Landre, 20, of Lacey Township.

After graduating as the valedictorian of Freehold Township High School, Landre and her family spent months putting everything in place so she could go away to college in Washington, D.C., using scholarships and financial aid grants for her tuition and Medicaid money to pay for her care.

Landre, who has spinal muscular atrophy type 2, a neuromuscular disease that causes muscle weakness and breathing problems, hired Georgetown nursing students to help her in two-hour shifts between classes during the day and at night to help turn her in bed and use her breathing machine. Her health insurance covered the costs of the aides.

With the aides working staggered shifts, Landre did well in her first two years at Georgetown. She earned a 3.9 GPA, made close friends, scored an internship and wrote a column for the school paper.

Now, she will have to drop out because of out-of-date New Jersey rules that determine the number of hours of care a person needs based on the outdated assumption that those with severe disabilities are homebound, she says.

“This isn’t just a me problem,” said Landre. “These programs are so antiquated in their design in that they don’t allow for people to go away to college or for having a career."

As a disabled woman & wheelchair user, I’ve been fending off my insurance company’s cuts for years. Today, they finally got a judge to side with them—and now I can’t go back to college next semester. The American healthcare system has just, quite literally, ruined my future. — Anna ♿️ (@annalandre) May 28, 2019

Like many people with severe disabilities, Landre is on Medicaid, the federal- and state-administered health insurance program for those with limited means for their care. In her case, the state government has contracted her health insurance to Horizon NJ Health, a private health insurance company that is part of Horizon Blue Cross Blue Shield network.

When asked about Landre’s case, the health insurance company said it is just following the rules.

“Horizon New Jersey Health takes seriously the needs of our members not because it is required by law or contract, but because doing so is a principle that guides our conduct every day. As a Medicaid managed care organization, HNJH administers the Medicaid program according to rules set by the federal and state agencies that fund Medicaid,” the company said in a statement.

Horizon has no control over the rules that determine how many hours of paid home care a patient needs a day. “Rather, HNJH is required to follow the protocols and rules established by the program’s federal and state administrators,” the company said.

Landre’s problems began in January 2018 when Horizon NJ Health sent someone to reassess how much “personal care assistance” she needed at college. Using a formula that gave her a certain number of minutes for each need -- including cooking, getting dressed, going to the bathroom and getting hooked up to a breathing assistance machine at night -- the health insurance company said her hours would be reduced from 16 hours of paid health aide care each day to 10 hours.

Landre calculated it would cost her about $35,000 a year if she paid the health aides at Georgetown out of her own pocket for the extra six hours a day the health insurance company refused to pay. Her family, which includes two younger brothers and two younger step siblings back in New Jersey, can’t afford that kind of additional expense, she said.

Landre’s first appealed to the health insurance company, arguing there was no way she could live alone at college with so little help for her personal needs. But the health insurance company rejected her internal appeal in June 2018.

Then, she got an attorney with the Community Health Law Project, a nonprofit legal services agency, to help her appeal the decision to a state administrative law judge.

The judge ruled in Landre’s favor in February, saying the tools health insurance companies use to determine a young person’s care don’t fully consider “day to day living as an on-campus college student.”

The judge ordered Horizon NJ Health not to cut Landre’s health aide hours.

“While there is little precedent in the current regulations for disabled college students living at school, the reasonable interpretation of the regulations does not limit a disabled college student’s medically necessary home care services while living at school,” Mary Ann Bogan, the administrative law judge, wrote in her decision.

Landre continued her classes at Georgetown, assuming the case was closed. However, the judge’s decision then went to the state Department of Human Services for review.

She was surprised to get a final decision from the state Division of Medical Assistance and Health Services in May reversing the judge’s ruling. It said her home health aide hours would be reduced 40 percent, from 16 hours to 10 hours a day.

A spokesman for the state Department of Human Services declined to comment on Landre’s case.

“The department cannot comment on specific cases, but our priority is always to ensure that individuals have access to the services and benefits for which they are eligible to meet their needs,” Department of Human Services officials said in a statement.

Landre said she plans to appeal the decision to the state appellate court.

She has spread her story on social media, asking for help, and has heard from some lawmakers, including the office of Sen. Cory Booker (D-N.J.). Georgetown University officials have also reached out to her, offering to look for ways to help her, but they have not found a solution.

Landre said she has thought through other ideas, including asking the friends living in her campus suite to help out with her care, but she immediately rejected that as unfair and impractical. Asking her mother to quit her job in New Jersey and come live with her at college also seemed unfair to the rest of her family.

Georgetown does not offer any online or distance learning options for her degree in regional and comparative studies, she said.

She has dismissed the idea of starting a GoFundMe page to pay for her care, partly because it will not help other students who might be facing the same cuts in care.

For now, Landre said she is putting her junior year at Georgetown on hold, along with her dreams of using her degree to get a job in the State Department or the foreign service.

She said she plans on continuing to speak out on behalf of the growing number of students with disabilities dreaming of going away to college.

“I have come across so many people from New Jersey who tried to do this, but have been blocked,” Landre said. “Other states have the same problems.”

Kelly Heyboer may be reached at kheyboer@njadvancemedia.com. Follow her on Twitter @KellyHeyboer. Find her at KellyHeyboerReporter on Facebook. Find NJ.com on Facebook.

Have a tip? Tell us. nj.com/tips

Get the latest updates right in your inbox. Subscribe to NJ.com’s newsletters.