Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave. Elkins, WV 26241 March 19, 2014 Karen L. Bowling Cabinet Secretary Margaret Waldeck for Kathleen Schultz 200 Emerson Rd. Clarksburg, WV 26301 RE: SCHULTZ v. WVDHHR ACTION NO.: Dear Ms. Waldeck: 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. Encl: Claimant s Recourse to Hearing Decision Form IG-BR-29 Sincerely, Pamela L. Hinzman State Hearing Officer Member, State Board of Review cc: Eva Marie Dawson, WVDHHR
WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BOARD OF REVIEW KATHLEEN SCHULTZ, Claimant, v. Action Number: 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 Kathleen Schultz. 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 March 11, 2014, on an appeal filed January 7, 2014. The matter before the Hearing Officer arises from the November 13, 2013 decision by the Respondent to deny the Claimant s application for benefits under the Long-Term Care Medicaid Program. At the hearing, the Respondent appeared by Eva Marie Dawson, Economic Service Worker, WVDHHR. The Claimant appeared pro se by her niece/attorney-in-fact, Margaret Waldeck. Department's Exhibits: D-1 Medicaid application received by WVDHHR on August 27, 2013 D-2 Notice of Decision dated November 13, 2013 D-3 West Virginia Income Maintenance Manual Chapter 17.11.A D-4 West Virginia Income Maintenance Manual Chapter 17.11.B D-5 Verification checklist dated October 1, 2013 D-6 West Virginia Income Maintenance Manual Chapter 4.1 D-7 West Virginia Income Maintenance Manual Chapter 17.10 D-8 West Virginia Income Maintenance Manual Chapter 11.3 D-9 BB&T OnLine checking account information D-10 West Virginia Income Maintenance Manual Chapter 11.2 D-11 West Virginia Income Maintenance Manual Chapter 17.10 D-12 Verification checklist returned to WVDHHR on October 7, 2013 D-13 Copy of deeds and property tax information
Claimant s Exhibits: C-1 Financial information 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 Hearing Officer sets forth the following Findings of Fact. FINDINGS OF FACT 1) On August 27, 2013, the Claimant applied for Long-Term Care Medicaid via Margaret Waldeck, her niece/attorney-in Fact (see Exhibit D-1). 2) The Department issued a verification checklist (D-5) to the Claimant on October 1, 2013, requesting that the Claimant provide an approved Pre-Admission Screening (PAS) form to verify medical necessity for Long-Term Care services. In addition, the Claimant was asked to provide bank statements, and to provide information concerning the value of a rental property business she transferred in 2009. 3) Economic Service Worker (ESW) Eva Marie Dawson testified that the Claimant failed to provide a PAS form; therefore, medical necessity for nursing facility services could not be determined. In addition, the Claimant s representative provided bank statements (D-9), which indicated that the Claimant s checking account balance exceeded $2,000 on the first moment of the month of August, September and October 2013. While some information (D-12 and D-13) was received concerning the business the Claimant transferred to Ms. Waldeck in 2009, documentation was insufficient to determine the value of the business at the time of the transfer. 4) The Department sent the Claimant a Notice of Decision on November 13, 2013 (D-2), informing her that the Long-Term Care Medicaid application was denied based on excessive assets and failure to provide all requested information. 5) During the hearing, Ms. Waldeck testified that she had operated the rental property business with her aunt since 1993 prior to its transfer. She stated that her aunt does not have enough income to pay for the cost of her nursing home care, and that she (Ms. Waldeck) has had to take out loans to pay for her care. Ms. Waldeck provided a statement (C-1) to indicate that rental income from the business and her aunt s retirement income fall $26,043 short of paying for the annual cost of her care. She stated that she is desperate and can no longer afford to contribute her own money to her aunt s care.
APPLICABLE POLICY West Virginia Income Maintenance Manual Chapters 17.11.A and B (D-3 and D-4) state that before payment for nursing facility services can be made, medical necessity must be established by a PAS evaluation when an applicant is not a recipient of Medicaid under a full-coverage Medicaid group. Chapter 17.10 of the Manual (D-7) states that a nursing care client must meet the asset test for his eligibility coverage group. Chapter 11.3 of the Manual (D-8) specifies that the asset limit for a one-person Medicaid Assistance Group is $2,000. Chapter 11.2.A (D-10) indicates that the asset eligibility determination for SSI-Related Medicaid (Long-Term Care) applications must be made as of the first moment of the month of application. The client is not eligible for any month in which countable assets are in excess of the maximum as of the first moment of the month. Chapter 17.10.B.3.b (D-11) states that the look-back period for resource transfers is 60 months for the purposes of determining Long-Term Care Medicaid eligibility. Chapter 4.1.A of the Manual (D-6) states that the primary responsibility for providing verification rests with the client. Failure of the client to provide necessary information results in denial of the application provided that the client has access to such information and is physically and mentally able to provide it. DISCUSSION An individual must be determined medically and financially eligible to qualify for Long-Term Care Medicaid benefits. The Department did not receive verification of the Claimant s medical eligibility, and confirmed that her assets exceeded the limit of $2,000. In addition, the Department could not determine the value of the Claimant s former rental business - at the time of the asset transfer - with the information provided. CONCLUSIONS OF LAW Whereas evidence demonstrates that medical eligibility was not verified, the value of a 2009 property transfer could not be determined and the Claimant s checking account assets were excessive, the Department acted correctly in denying the Claimant s Long-Term Care Medicaid application.
DECISION It is the decision of the State Hearing Officer to UPHOLD the Department s action to deny the Claimant s application for Long-Term Care Medicaid benefits. ENTERED this 19 th Day of March 2014. Pamela L. Hinzman State Hearing Officer