October 29, Enclosed is a copy of the decision resulting from the hearing held in the above-referenced matter.

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1 STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES OFFICE OF INSPECTOR GENERAL Earl Ray Tomblin BOARD OF REVIEW Karen L. Bowling Governor 4190 Washington Street, West Cabinet Secretary Charleston, West Virginia (304) , ext October 29, 2014 RE: v. WV DHHR ACTION NO.: 14-BOR-3162 Dear : Enclosed is a copy of the decision resulting from the hearing held in the above-referenced matter. 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. You will find attached an explanation of possible actions you may take if you disagree with the decision reached in this matter. Sincerely, Donna L. Toler State Hearing Officer Member, State Board of Review Encl: Claimant s Recourse to Hearing Decision Form IG-BR-29 cc: Misty Fielder, Economic Service Worker

2 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BOARD OF REVIEW, Claimant, v. Action Number: 14-BOR-3162 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES, Respondent. DECISION OF STATE HEARING OFFICER INTRODUCTION This is the decision of the State Hearing Officer resulting from a fair hearing for. This hearing was held in accordance with the provisions found in Chapter 700 of the West Virginia Department of Health and Human Resources Common Chapters Manual. This fair hearing was convened on October 29, 2014, on an appeal filed September 16, The matter before the Hearing Officer arises from the September 11, 2014 decision by the Respondent to deny Claimant s application for Medicare Premium Assistance. At the hearing, the Respondent appeared by Misty Fielder, Economic Service Worker. The Grievant appeared pro se. All witnesses were sworn and the following documents were admitted into evidence. Department's Exhibits: D-1 Correspondence from DHHR to, dated September 11, 2014 D-2 West Virginia Income Maintenance Manual D-3 West Virginia Income Maintenance Manual 10, Appendix A D-4 West Virginia Income Maintenance Manual 16.6 D-5 Unearned Income computer screen print, print date September 18, 2014 Claimant s Exhibits: None After a review of the record, including testimony, exhibits, and stipulations admitted into evidence at the hearing, and after assessing the credibility of all witnesses and weighing the 14-BOR-3162 Page 1

3 evidence in consideration of the same, the Hearing Officer sets forth the following Findings of Fact. FINDINGS OF FACT 1) The Claimant was a recipient of Medicare Premium Assistance known as Qualified Individual Medicaid, also known as QIA or QI-1 (hereinafter QIA). 2) On September 11, 2014, the Department mailed notice to the Claimant that he was denied Medicare Premium Assistance benefits because his income is more than the income limit for you to receive benefits. (Exhibit D-1) 3) The Department contended that because the Claimant s income, with allowable deductions, exceeded the income limit set forth in policy for QIA eligibility, it was correct in its decision to deny his application for continued coverage. (Exhibits D-2, D- 3 and D-4) 4) The Department representative, Misty Fielder (Ms. Fielder) testified that the Claimant is a recipient of Social Security Disability benefits and his gross income of $1442 (Exhibit D-5) was verified via the Department s State On-Line Query (SOLQ), a State database which interfaces with the Social Security Administration. Ms. Fielder explained that the Claimant was eligible for a $20 disregard from his gross income of $1442, which resulted in a countable income of $1422. Ms. Fielder reported that the gross income limit for QIA is $1313 (Exhibit D-3), and that the Claimant s countable income of $1422 was in excess of the limits set forth in policy. Ms. Fielder added that even had the Claimant been income eligible for QIA coverage, that he is eligible for a fullcoverage Medicaid benefit and that policy precludes individuals receiving a fullcoverage Medicaid benefit from receiving Medicare Premium Assistance benefits. 5) The Claimant did not dispute that his income was in excess of the policy limits, but questioned why he had historically received Medicare Premium Assistance even though his income was always over the established income limit. The Department representative indicated that she did not know why he had been approved previously, but that it appeared to be an error in their computer system, which was not discovered by the eligibility workers prior to confirming the benefit in the past. 6) The Claimant stated that he was appreciative of the Medicare Premium Assistance he had received from the Department in the past. He explained that he is unable to afford the Medicare Part B premium because his expenses exceed his income. The Claimant reported that because of his current debt, his monthly expenses total $1506 per month, which does not include the cost of groceries. The Claimant added that his Medicare paid in excess of $50,000 for calendar year 2013 and that he anticipated his expenses to exceed $48,000 for The Claimant requested that if a waiver or exception to policy existed, he would be grateful if the Department could continue paying his Medicare premiums. 14-BOR-3162 Page 2

4 APPLICABLE POLICY West Virginia Income Maintenance Manual (WV IMM) outlines the procedure for determining financial eligibility for Medicare Premium Assistance benefits, which includes QIA. Countable income is determined by subtracting appropriate disregards ($20) from the individual s gross income. If the individual s gross income is greater than 120% of the Federal Poverty Level (FPL), but less than or equal to 135% FPL, the individual is eligible for QIA. WV IMM 10, Appendix A, is a chart of income limits for various programs of assistance available through the West Virginia Department of Health and Human Resources, the income limits for QIA coverage range from $1168 to $1313 per month. WV IMM 16.6.E, outlines the specific Medicaid requirements for eligibility under the QIA program. Individuals who are eligible for any full-coverage Medicaid group are not eligible for QIA coverage. DISCUSSION The Claimant did not dispute that his countable income was in excess of the limits established by policy for Medicare Premium Assistance eligibility, but contended that he was unable to afford his Medicare Part B premium. The Claimant requested that if a waiver or exception to policy was available, that it be granted to him. However, policy contains no waivers or exceptions to the income calculation methods or income guidelines when determining eligibility for Medicare Premium Assistance. CONCLUSION OF LAW Because the Claimant s gross monthly income is in excess of the Federal Poverty Level limit of $1313 per month for eligibility under the QIA Medicare Premium Assistance program, the Department acted correctly to find him ineligible for QIA coverage, in accordance with West Virginia Income Maintenance Manual and Appendix A. 14-BOR-3162 Page 3

5 DECISION It is the decision of the state Hearing Officer to uphold the Department s denial of Claimant s application for Qualified Individual (QIA) Medicare Premium Assistance benefits. ENTERED this Day of October, Donna L. Toler State Hearing Officer 14-BOR-3162 Page 4