State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave.

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1 Joe Manchin III Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave. Elkins, WV Martha Yeager Walker Secretary March 12, Dear -----: Attached is a copy of the findings of fact and conclusions of law on your hearing held March 5, Your hearing request was based on the Department of Health and Human Resources calculation of your Community Spouse Maintenance Allowance (CSMA). In arriving at a decision, the State Hearing Officer is governed by the Public Welfare Laws of West Virginia and the rules and regulations established by the Department of Health and Human Resources. These same laws and regulations are used in all cases to assure that all persons are treated alike. Eligibility for the Medicaid Long-Term Care Program is based on current policy and regulations. Some of these regulations state as follows: When the institutionalized individual has a spouse living in the community, a portion of his income may be deducted for the support of the spouse at home. To determine the CSMA, the income of the community spouse is subtracted from a Spousal Maintenance Standard (SMS). (West Virginia Income Maintenance Manual Chapter 17.9) Information presented during your hearing reveals that the Agency accurately calculated the maintenance allowance you receive in conjunction with your husband s Long-Term Care benefits. It is the decision of the State Hearing Officer to uphold the Department s determination of your Community Spouse Maintenance Allowance. Sincerely, Pamela L. Hinzman State Hearing Officer Member, State Board of Review cc: Erika H. Young, Chairman, Board of Review Sharon Straley, Family Support Supervisor, DHHR

2 WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES BOARD OF REVIEW -----, Claimant, v. Action Number: 09-BOR- 656 West Virginia Department of Health and Human Resources, Respondent. DECISION OF STATE HEARING OFFICER I. INTRODUCTION: This is a report of the State Hearing Officer resulting from a fair hearing concluded on March 12, 2009 for and This hearing was held in accordance with the provisions found in the Common Chapters Manual, Chapter 700 of the West Virginia Department of Health and Human Resources. This fair hearing was convened on March 5, 2009 on a timely appeal filed February 6, II. PROGRAM PURPOSE: The program entitled Long-Term Care is set up cooperatively between the Federal and State governments and administered by the West Virginia Department of Health & Human Resources. Long-Term Care is a medical service which is covered by the State's Medicaid Program. Payment for care is made to nursing homes which meet Title XIX (Medicaid) standards for the care provided to eligible recipients. In order to qualify for Nursing Home Care, an individual must meet financial and medical eligibility criteria. III. PARTICIPANTS: -----, Claimant Sharon Straley, Family Support Supervisor, DHHR Angela Jennings, Economic Service Worker, DHHR Presiding at the hearing was Pamela L. Hinzman, State Hearing Officer and a member of the State Board of Review

3 IV. QUESTIONS TO BE DECIDED: The question(s) to be decided is whether the Agency was correct in its determination of the Community Spouse Maintenance Allowance in conjunction with the Claimant s Long-Term Care benefits. V. APPLICABLE POLICY: West Virginia Income Maintenance Manual Chapters, 10.22, 17.9 and 10, Appendix A West Virginia DHHR Common Chapters Manual Section C VI. LISTING OF DOCUMENTARY EVIDENCE ADMITTED: Department s Exhibits: D-1 West Virginia Income Maintenance Manual Chapters and 17.9 D-2 Notice of Decision dated January 27, 2009 D-3 Notice of Decision dated February 4, 2009 D-4 Notice of Contribution to the Cost of Care dated February 3, 2009 D-5 Notice of Contribution to the Cost of Care dated February 13, 2009 D-6 West Virginia Income Maintenance Manual Chapter 10, Appendix A D-7 Spousal Impoverishment Income Allocation Budget Claimant s Exhibits C-1 Information concerning Claimant s household expenses VII. FINDINGS OF FACT: 1) is a recipient of Medicaid Long-Term Care benefits and currently resides at Cortland Acres Nursing Home. 2) The Department completed post-eligibility calculations and determined that s wife, , is entitled to a Community Spouse Maintenance Allowance (CSMA) of $1, The CSMA is calculated based on s gross, non-excluded income of $2, per month and s gross, non-excluded income of $ ) The Agency calculated the Community Spouse Maintenance Allowance (D-7) as follows: $1,750 (minimum Spousal Maintenance Standard) minus $ (----- s gross, nonexcluded income) = $1, (Community Spouse Maintenance Allowance). 4) The Family Support Supervisor testified that the Claimant was previously receiving a higher CSMA, but no longer qualifies for shelter and utility deductions because she does not reside in the same residence she shared with her husband prior to his - 2 -

4 institutionalization. In addition, the Claimant is no longer paying a private health insurance premium for which an income deduction was previously allowed. 5) The Claimant testified that she sold the residence she shared with her husband after he was admitted to Cortland Acres. The Claimant testified that she could no longer manage upkeep of the property, so she purchased a duplex at Cortland Acres and pays a maintenance fee and utilities at the residence. She provided a statement detailing her monthly expenses (C-1). 6) West Virginia Income Maintenance Policy Chapter 17.9 D (D-1) states, in pertinent part: When the institutionalized individual has a spouse living in the community, a portion of his income may be deducted for the support of the spouse at home. To determine the CSMA, the income of the community spouse is subtracted from a Spousal Maintenance Standard (SMS) which is either: - The minimum SMS. This is 150% of the monthly FPL for 2 persons; or - The minimum SMS, increased by excess shelter/utility expenses, but not exceeding the maximum SMS. See Chapter 10, Appendix A for the minimum and maximum Spousal Maintenance Standard amounts. The following steps are used to determine the amount of the CSMA: Step 1: Add together the actual shelter cost and the amount of the current Food Stamp Heating/Cooling Standard (HCS). See Chapter 10, Appendix B. The shelter cost must be from the home the institutionalized spouse and the community spouse shared prior to institutionalization, and in which the community spouse continues to live. It must have been the client s principal place of residence. Step 2: Compare the total of the costs in Step 1 to 30% of the minimum SMS. See Chapter 10, Appendix A. When the shelter/utility costs exceed 30% of the minimum SMS, subtract the 30% amount from the shelter/utility costs. Step 3: Add the remainder from Step 2 to the minimum SMS. This amount, not to exceed the maximum SMS, is used in Step 5. See Chapter 10, Appendix A. Step 4: Add together the community spouse s gross, nonexcluded earned and unearned income

5 Step 5: Subtract the Step 4 amount from the amount determined in Step 3 and if there are any cents, round the resulting amount up. This is the amount subtracted from the income of the institutionalized spouse for the needs of his community spouse. If the Step 4 amount is equal to or greater than the Step 3 amount, no deduction is allowed. 7) West Virginia Income Maintenance Manual Chapter 10, Appendix A (D-6) states that the Minimum SMS is $1,750, while the maximum SMS is $2,739. 8) West Virginia Income Maintenance Manual Chapter (D-1) states that health insurance premiums, including Medicare or the enrollment fee for a Medicare-approved discount drug card, are allowable spenddown expenses. 9) WVDHHR Common Chapters Manual Section C states: If it is established that the community spouse needs income above levels otherwise provided by the minimum monthly maintenance needs allowance due to exceptional circumstances resulting in significant financial duress, there shall be substituted an amount adequate to provide such additional income as necessary. VIII. CONCLUSIONS OF LAW: 1) Policy reveals that the Department must complete calculations to determine the Community Spouse Maintenance Allowance when an institutionalized individual has a spouse living in the community. 2) Based on the s countable monthly income, the Department calculated s Community Spouse Maintenance Allowance as $1, per month based on policy found in West Virginia Income Maintenance Manual Chapter The calculations are as follows: Step 1: No shelter/utility costs considered as no longer resides in the home in which she resided with her husband prior to his institutionalization. Step 2: Compare total shelter/utility costs ($0) to 30% of minimum Spousal Maintenance Standard ($1,750 x 30% = $525) Because shelter/utility costs cannot be counted, they do not exceed 30% of the minimum Spousal Maintenance Standard ($525). Step 3: No remainder from Step 2 is added to the minimum Spousal Maintenance Standard of $1,750 since - 4 -

6 shelter/utility costs do not exceed 30% of the minimum Spousal Maintenance Standard. Step 4: s gross, non-excluded income is $ per month. Step 5: $1,750 (minimum Spousal Maintenance Standard) - $ (----- s income) = $1, total Community Spouse Maintenance Allowance. 3) The Department s calculation of a $1, Community Spouse Maintenance Allowance is correct based on information presented during the hearing. 4) The DHHR Common Chapters Manual stipulates that the Hearing Officer may grant a greater monthly maintenance allowance due to exceptional circumstances resulting in significant financial duress (emphasis added). No evidence was presented during the hearing to demonstrate that exceptional circumstances result in incurring significant financial duress receives $1,750 per month, which includes her gross unearned income of $ and the Community Spouse Maintenance Allowance of $1, It should be noted that $96.40 of s Social Security income is deducted for a Medicare premium, bringing her total net income to $1, reported monthly household expenses totaling $1, While it is noted that the identified monthly expenses include neither food nor bills paid only on an annual basis, some items on the monthly expense list are not essential to the community spouse s wellbeing. Therefore, the amount of the Community Spouse Maintenance Allowance, as determined by the Department, cannot be altered because significant financial duress has not been demonstrated. IX. DECISION: It is the decision of the State Hearing Officer to uphold the Agency s calculation of the Community Spouse Maintenance Allowance. X. RIGHT OF APPEAL: See Attachment XI. ATTACHMENTS: The Claimant s Recourse to Hearing Decision Form IG-BR

7 ENTERED this 12th Day of March, Pamela L. Hinzman State Hearing Officer - 6 -