MGE 207780 (07/14/2023)
Application denied, petitioner failed to report first date of institutionalization

Preliminary Recitals

Pursuant to a petition filed on February 23, 2023, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Milwaukee Enrollment Services regarding Medical Assistance (MA), a hearing was held on June 21, 2023, by telephone.

The issue for determination is whether the agency correctly denied Petitioner’s MA application on February 8, 2023.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Kyra Oberg
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, WI 53205

ADMINISTRATIVE LAW JUDGE:
Nicole Bjork
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a resident of Milwaukee County.
2. On November 15, 2022, Petitioner applied for MA benefits. The application did not disclose any past institutional stays, prompting the agency to complete a spousal assessment.
3. On February 8, 2023, the application was denied because Petitioner was over the asset limit to be approved.
4. On February 23, 2023, Petitioner filed an appeal of the February 8, 2023, denial notice, which is the issue for this appeal.
5. On March 1, 2023, Petitioner submitted a new application for MA benefits. The agency was informed at this time that Petitioner had a lengthy hospital stay from February 2018 through October 2018, costing Petitioner over a million dollars in private pay medical costs. Based on this new information, the agency requested verification of the institutional stay from 2018, along with all assets from 2018 to present.
6. On March 20, 2023, the agency approved Petitioner’s MA application, effective March 1, 2023.
7. At hearing, the agency representative noted that if the agency had been aware of Petitioner’s 2018 hospital stay, the November 2022 application would have been approved. However, the agency was not aware of that hospital stay until March 1, 2023.
8. Petitioner’s spouse testified at hearing that he had informed “Tameekah” who is “from the county” about the 2018 institutional stay. Petitioner’s spouse believed that all the agencies were connected and that if he told one person from one agency, then all the agencies would be aware. The agency representative then testified that the agency was completely unaware of any conversations he had with representatives from other agencies and that the only way the agency would have known about the 2018 institutional stay would be if Petitioner had informed them or written that in the application, which Petitioner did not.

Discussion

Medical Assistance long-term care waiver programs in Wisconsin include Family Care, Partnership, PACE, and IRIS. These programs are administered by the Department of Health Services and are designed to provide appropriate long-term care services for elderly individuals and individuals with physical or intellectual disabilities. To be eligible, a person must be functionally eligible and generally must also be financially and non-financially eligible for a “full benefit category of [Elderly, Blind, Disabled] Medicaid.” See Medicaid Eligibility Handbook §28.1.2. Accordingly, an individual who is interested in participating in a long-term care waiver program is expected to undergo a functional eligibility screen, to complete an application to establish financial and non-financial Medicaid eligibility, and finally, to go through an enrollment process. See, e.g., https://www.dhs.wisconsin.gov/familycare/apply.htm.

To be financially eligible for any of the “full benefit Elderly, Blind, Disabled programs” applicable to Petitioner (i.e., SSI-related Medicaid, SSI Medicaid, Institutional Medicaid), an individual cannot have more than $2,000 in countable assets. Medicaid Eligibility Handbook §§1.1.2 and 39.4.1.

At the time the November 2022 application was submitted, Petitioner also documented her assets. The agency verified that her assets including — Checking account of $1513.43, — Checking account of $9860.84, — Savings account of $841.90, — Investment Portfolio of $47,223.86, and — Investment Portfolio of $37,542.99. Because those verified assets were over $2,000, the agency denied Petitioner’s application.

Petitioner’s husband noted that Petitioner had a lengthy hospital stay in 2018, which was not considered when the November 2022 application was denied. The agency representative did confirm that Petitioner would have been determined to be eligible if the agency was aware of the 2018 hospital stay prior to the denial. However, the agency representative noted that Petitioner never informed the agency of the 2018 hospital stay, nor did the application note that Petitioner had a lengthy hospital stay in 2018 that cost Petitioner over a million dollars in private pay care. Petitioner’s husband testified that he did tell an agency worker from a different agency about the hospital stay and that he assumed telling one agency would mean that all agencies would be informed. Petitioner’s husband did not explain why he believed telling one agency would mean that all of the agencies would be aware of that information.

Petitioner’s husband argues that the November 2022 application was incorrectly denied as over assets because the 2018 hospital stay wasn’t considered. Petitioner’s husband believes that the application should have been approved with coverage starting in December 2022. However, the agency denied the application based on the evidence and facts that it had at the time the decision was made. At the time the decision was made, the agency was unaware of the hospital stay. Petitioner had an obligation to ensure that the agency had all relevant information to make an informed decision. I cannot find that the agency denied the November 2022 application in error. At the time that decision was made, the agency was unaware of the 2018 hospital stay. Thus, they correctly determined that Petitioner was over assets to be approved for coverage since the verified information demonstrated that Petitioner was over assets at that time.

For the reasons set forth above, I find that the agency correctly denied the November 2022 application based on the information that the agency had at that time.

Conclusions of Law

The agency correctly denied Petitioner’s MA application based on the information that the agency had at that time.

THEREFORE, it is

Ordered

That Petitioner’s appeal is dismissed.

[Request for a rehearing and appeal to court instructions omitted.]