State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review Post Office Box 1736 Romney, WV 26757

Transcription

1 Joe Manchin III Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review Post Office Box 1736 Romney, WV Martha Yeager Walker Secretary May 21, 2008 Dear Ms. : Attached is a copy of the findings of fact and conclusions of law on your hearing held May 14, Your hearing request was based on the Department of Health and Human Resources proposal to discontinue your Qualified Medicare Beneficiaries (QMB) coverage. In arriving at a decision, the State Hearings 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 QMB coverage is based on current policy and regulations. Some of these regulations state as follows: Countable income must be less than or equal to 100% of the Federal Poverty Level. The information, which was submitted at your hearing, revealed that your countable income after deductions exceeds 100% of the Federal Poverty Level. It is the decision of the State Hearings Officer to uphold the action of the Department to discontinue your QMB coverage. Sincerely, Sharon K. Yoho State Hearing Officer Member, State Board of Review cc: Erika H. Young, Chairman, Board of Review Ann Hubbard, DHHR

2 WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES BOARD OF REVIEW - Claimant, v. Action Number: 08-BOR-1184 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 May 14, 2008 for. 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 May 14, 2008 on a timely appeal, filed February 4, II. PROGRAM PURPOSE: The Program entitled Medicaid is set up cooperatively between the Federal and State governments and administered by the West Virginia Department of Health & Human Resources. The 1965 Amendments to the Social Security Act established, under Title XIX,a Federal-State medical assistance program commonly known as Medicaid. The Department of Health and Human Resources administers the Medicaid Program in West Virginia in accordance with Federal Regulations. The Bureau for Medical Services is responsible for development of regulations to implement Federal and State requirements for the program. The Department of Health and Human Resources processes claims for reimbursements to providers participating in the program

3 III. PARTICIPANTS: Claimant s Witnesses:, claimant, claimant s wife Department s Witnesses: Donald Tolliver, Income Maintenance Worker Presiding at the Hearing was Sharon K. Yoho, State Hearing Officer and a member of the State Board of Review. IV. QUESTIONS TO BE DECIDED: The question(s) to be decided is whether the agency was correct in their action to discontinue QMB coverage. V. APPLICABLE POLICY: West Virginia Income Maintenance Manual 16.6, 10.16, and Chapter 10, Appendix A VI. LISTING OF DOCUMENTARY EVIDENCE ADMITTED: Department s Exhibits: D-1 Computer screen Individual Demographics D-2 Computer screen SSA Benefit Details D-3 Computer screen Eligibility Determination D-4 West Virginia Income Maintenance Manual, Chapter 10 Appendix A D-5 Notification letter dated January 26, 2008 D-6 West Virginia Income Maintenance Manual, VII. FINDINGS OF FACT: 1) The claimant s case received an automatic update to reflect her new Social Security income in January Her increased Social Security income put her over the income guidelines for her Qualified Medicare Beneficiaries (QMB) benefits. 2) The claimant s new income was reported by the Social Security Administration to be $890. The Department applied this new income to the income guidelines for QMB by subtracting the standard deduction of $20. this left $870. as countable income. 3) The countable income of $870 was applied to 100% of the Federal Poverty Level of $867. The Department issued a closure letter on January 26, 2008 advising the claimant that her QMB benefits would discontinue

4 4) The claimant testified of her disbelief that if her income is just $3. over the income limits that this would cause her to be ineligible for the benefit. She indicated that she has breast cancer and has medical expenses that Medicare does not cover. 5) The Department s representative began discussion with the claimant about the Medicaid program for Breast and Cervical cancer screenings and treatment. The hearing was adjourned and the claimant and worker were left to continue this discussion. 6) West Virginia Income Maintenance Manual 16.6: QUALIFIED MEDICARE BENEFICIARIES (QMB) Income: 100% FPL Assets: $4,000 Individual $6,000 Couple The individual or couple must meet the income test detailed in Chapter 10 Medicaid coverage is limited to payment of the Medicare, Part A and Part B premium amounts and payment of all Medicare co-insurance and deductibles, including those related to nursing facility services. 7) West Virginia Income Maintenance Manual 10.16: MEDICAID FOR (QMB) Note: The spenddown provision does not apply. A. Income disregards and deductions See Section for SSI disregards and deductions B. Determining Eligibility Countable income is determined by subtracting any allowable disregards and deductions from the total non-excluded gross income. QMB Income is less than or equal to 100% FPL 8) West Virginia Income Maintenance Manual SSI-RELATED MEDICAID (Medically Needy, Mandatory) B. INCOME DISREGARDS AND DEDUCTIONS The following disregards and deductions are applied, if applicable. 1. Earned Income -SSI $20 Disregard: The remainder of the $20 income disregard not used against unearned income. -SSI Earned Income Disregard: $65 and ½ of the remainder are subtracted from earned income and from gross profit from selfemployment earnings. 2. Unearned Income -SSI $20 Disregard: A $20 Disregard is applied to the total gross unearned income. If the unearned income is less than $20, the remainder is subtracted from earned income, prior to the application of any other earned income disregards and deductions

5 9) West Virginia Income Maintenance Manual Chapter 10 Appendix A Number of Persons 100% FPL Income Limits: QMB 867 VIII. CONCLUSIONS OF LAW: 1) Policy and 16.6 provides that income limits for the QMB Medicaid program is 100% of the Federal Poverty Level (FPL). Appendix A of Chapter 10 clearly notes that 100% of the (FPL) for one person is $867. The claimant s countable income exceeded this amount. 2) Policy allows for only a $20. disregard to unearned income. The Claimant s Social Security gross income was $890. After applying the $20. disregard, the claimant s countable income was $870. This income while only $3. over the allowable income, clearly exceeded the income limits for the QMB program. 3) The Department correctly applied the $20. disregard to the unearned income and the correctly applied the countable income to the FPL listed on Chapter 10 Appendix A. IX. DECISION: Evidence and testimony given at this hearing clearly reveals that the Department correctly assessed income for the QMB Medicaid program. It is the ruling of this Hearing Officer to uphold the Department in their action to discontinue this Medicaid coverage. X. RIGHT OF APPEAL: See Attachments XI. ATTACHMENTS: The Claimant s Recourse to Hearing Decision Form IG-BR-29 ENTERED this 21 th Day of May Sharon K. Yoho State Hearing Officer - 4 -