May 23, 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 Jim Justice BOARD OF REVIEW Bill J. Crouch Governor 416 Adams St. Cabinet Secretary Suite 307 Fairmont, WV ext May 23, 2017 RE: v. WVDHHR ACTION NO.: 17-BOR-1708 Dear Mr. Enclosed is a copy of the decision resulting from the hearing held in the above-referenced matter. In arriving at a decision, the Board of Review 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 that may be taken if you disagree with the decision reached in this matter. Sincerely, Enclosure: Claimant s Recourse to Hearing Decision Form IG-BR-29 cc: Kimberly Donley Tara B. Thompson State Hearing Officer State Board of Review

2 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BOARD OF REVIEW N, Appellant, v. ACTION NO.: 17-BOR-1708 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 May 18, 2017, on an appeal filed April 20, The matter before the Hearing Officer arises from the March 14, 2017 decision by the Department to deny Medicaid benefits. At the hearing, the Respondent appeared by Kimberly Donley. The Appellant appeared pro se. The Appellant testified on his own behalf. All witnesses were sworn and the following documents were admitted into evidence. Department's Exhibits: EXHIBITS D-1 West Virginia Department of Health and Human Resources notice of denial for Medicaid benefits D-2 West Virginia Income Maintenance Manual (WVIMM) section 10.8 D-3 WVIMM Appendix A: Income Limits 17-BOR-1708 P a g e 1

3 Appellant 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 evidence in consideration of the same, the following Findings of Fact are set forth. FINDINGS OF FACT 1) The Appellant applied for Medicaid benefits March 12, ) The Appellant reported employment with and $660 weekly income, but did not indicate that his employment was on a contracted basis. 3) The Appellant testified during the hearing that there was inadequate space on the form to report contracted basis information. 4) No information was given to reflect that the Respondent had matched the Appellant s selfattestation regarding his income with the federal data hub. 5) The Respondent calculated the Appellant s income based on customer statements; the Respondent did not verify the Appellant s income. The Respondent came up with an average $2,838 monthly Gross income. (Exhibit D-1) 6) The income limit for Adult Medicaid benefits for a one-person Assistance Group is $1,337 monthly. (Exhibit D-3) 7) The Respondent mailed the Appellant denial notice on March 14, (Exhibit D-1) 8) The Appellant is self-employed and filed a 1099 for his 2016 taxes. The Appellant contested that when he filed taxes his income was below the poverty line and should meet income requirements for eligibility. 9) The Respondent and the Appellant agreed to re-evaluate the Appellant s eligibility based on new information presented at the hearing that appropriate self-employed deductions could still be applied. APPLICABLE POLICY West Virginia Income Maintenance Manual 1.2 E reads as follows in part: The client s responsibility is to provide information about his circumstances so that the worker is able to make a correct decision about his eligibility. When the client is not able to provide the required verification, the Worker must assist him 17-BOR-1708 P a g e 2

4 WVIMM 4.1 C 1. reads: Reasonable compatibility refers to the process and result of reconciling discrepancies between an individual s self-attestation about his nonfinancial and financial information and the information reported by the federal hub or other electronic data source. WVIMM 4.1 C 3.a. reads: Applying reasonable compatibility to eligibility factors: Eligibility determination begins with the client s self-attestation regarding his non-financial and financial information. When available, client information is matched by the federal data hub or the electronic data source. Self-attestation is accepted without further verification for factors including name, age, and date of birth. The majority of eligibility factors are subject to the reasonable compatibility assessment when there is a discrepancy between the client s statement and information in the hub or other electronic data source. Discrepancies must be reconciled. First, the client must be given the chance to provide an explanation for the differences WV IMM 10.8 C reads in part: MAGI household income is the sum of the MAGI-based income of every individual included in the individual s MAGI household. The MAGI household is determined using the MAGI methodology... WV IMM 10.8 D reads in part: To calculate the MAGI determine the AGI (Adjusted Gross Income) figure for each member of the MAGI household whose income will count, for the current month. When applicable, the worker will use the budgeting method to anticipate future income amounts, consider past income sources, and build monthly income amounts based upon the applicant s reported income. 2. Adjustments to AGI The following items, which can be deducted from taxes, are subtracted from the individual s AGI. a. Educator expenses 17-BOR-1708 P a g e 3

5 b. Certain business expenses of reservists, performing artists, and fee-basis government officials. c. Health savings account deductions d. Moving expenses e. Deductible part of self-employment tax f. Self-employed SEP, SIMPLE, and qualified plans g. Self-employed health insurance deductions h. Penalty on early withdrawal of savings i. Alimony paid j. IRA deductions k. Student loan interest deductions l. Tuition and fees. WV IMM 10.8 F reads in part: The applicant s household income must be at or below the applicable modified adjusted gross income standard for the MAGI coverage groups. Step 1: Step 2: Step 3: Step 4: Determine the MAGI-based gross monthly income for each MAGI household income group. Convert the MAGI household s gross monthly income to a percentage of the Federal poverty level (FPL) by dividing current monthly income by 100% FPL for the household size. Convert the result to a percentage. Apply the 5% FPL disregard by subtracting 5 percentage points from the converted monthly gross income to determine the household income if it affects the applicant s eligibility for MAGI Medicaid After the 5% FPL income disregard has been applied, the remaining percent of FPL is the final figure that will be compared against the applicable modified adjusted gross income standard for the MAGI coverage groups. DISCUSSION The Appellant applied for Medicaid benefits March 12, 2017, and was issued a denial notice by the Respondent on March 14, The denial of Medicaid was based on the department s calculation that the Appellant s monthly gross income was $2,838, which was above 133% of the FPL for the size of the Appellant s Assistance Group. The Appellant is the only member of his Medicaid Assistance Group; therefore, his monthly income must be less than $1,337. The Appellant contests that his income was incorrectly calculated and that he should be eligible for Medicaid benefits. Per policy the Appellant is responsible for providing the Respondent with information about his circumstances so that the worker can make a correct decision about his eligibility. The Appellant notified the Respondent that he received $660 per week; however, he incorrectly 17-BOR-1708 P a g e 4

6 provided information about the source of his income. On his application, the Appellant indicated that he was employed at. The Respondent testified that the Respondent did not verify the Appellant s income; no other testimony or evidence were provided to reflect that the Respondent verified the Appellant s income through the federal data hub. Therefore, calculations made by the Respondent were incorrectly based on the Respondent s belief that was the Appellant s employer. During the hearing, the Appellant testified that he used a 1099 form when filing his taxes and contested that based on self-employed deductions his Gross income fell below 133% of the FPL. The Respondent testified that prior to the hearing the Department had no knowledge that the Appellant was self-employed and was not an employee of The Respondent testified that the Appellant s income could be given some deductions based on his self-employed status. The Respondent proffered that if the Appellant provided the Respondent with the Appellant s 2016 tax information that his income could be re-evaluated for benefit eligibility. The Appellant voiced agreement to providing the Respondent with requested tax documentation and having his eligibility reconsidered. CONCLUSIONS OF LAW 1) Pursuant to policy, it is the client s responsibility to provide information about his circumstances to that the worker is able to make a correct decision about his eligibility. 2) The Appellant s self-attestation regarding his financial information was not matched by the federal data hub or other electronic data source consistent with reasonable compatibility regarding MAGI Medicaid Groups. 3) The Appellant s income was incorrectly calculated as a result of the Respondent receiving incorrect information regarding the Appellant s self-employed status. 4) Pursuant to policy, the Appellant is eligible for some adjustment to his AGI based on his self-employed status. DECISION It is the decision of the State Hearing Officer to REVERSE the Department s decision to deny the Appellant Medicaid benefits. This matter is REMANDED this to the Department for recalculation of the Appellant s eligibility for MAGI Medicaid benefits. The Department will need to issue a new notice to the Appellant based on the re-calculation and if denied, notice must include the right to a fair hearing. ENTERED this 23rd day of May, Tara B. Thompson State Hearing Officer 17-BOR-1708 P a g e 5