After enrollment in a long-term care Medicaid program, the institutionalized spouse must spend down or transfer resources to the community spouse to get below $2,000 by the first renewal. In this case, the petitioner failed to do that but appealed the disenrollment and reduced her resources below $2,000 by the time of the hearing. ALJ Brian Schneider ordered elibility be continued:
I think petitioner’s husband did not understand that requirement, and their grandson helped them after the appeal was filed. At the hearing he provided evidence that petitioner’s assets are now below $2,000 and that the rest of the funds have been put in her husband’s name. I thus will order that petitioner’s MA be continued.
Preliminary Recitals
Pursuant to a petition filed September 29, 2023, under Wis. Stat., §49.45(5), to review a decision by Milwaukee Enrollment Services to discontinue Medical Assistance (MA), a hearing was held on December 13, 2023, by telephone. A hearing set for November 15, 2023 was rescheduled at the petitioner’s request.
The issue for determination is whether petitioner’s assets are over the MA limit.
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:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Milwaukee County.
- Petitioner resides with her husband. She has been eligible for the Family Care Program (FCP), considered to be institutionalized under Spousal Impoverishment rules. When a person is determined to be eligible under Spousal Impoverishment, the community spouse is told to transfer spousal assets to his name only, with exception that the eligible spouse can have assets under $2,000.
- In August, 2023, Milwaukee Enrollment Services conducted a renewal review of petitioner’s financial eligibility. It was discovered that there were three bank accounts that still had petitioner’s name on them, including a — account with $4,756 and a — savings account held jointly with her husband totaling $23,653.
- By a notice dated September 12, 2023, the agency informed petitioner that Medical Assistance (MA) would end October 1 because assets were over the limit. The discontinuance of MA would negatively impact petitioner’s FCP eligibility as well.
- An appeal was filed September 29, 2023. Benefits were continued pending this decision.
- The — account was closed. Petitioner’s husband opened a new account there in his name only. He also transferred $3,000 from the — account to the new — account. As of the hearing date petitioner’s accounts had balances below $2,000. She had no other assets affecting eligibility.
Discussion
The federal Medicaid Catastrophic Coverage Act of 1988 (MCAA) included extensive changes in state Medicaid (MA) eligibility determinations related to spousal impoverishment. In such cases an “institutionalized spouse” resides in a nursing home or in the community pursuant to MA Waiver eligibility including he FCP, and that person has a “community spouse” who is not institutionalized or eligible for MA Waiver services. Wis. Stat., §49.455(1).
When initially determining whether an institutionalized spouse is eligible for MA, county agencies are required to review the combined assets of the institutionalized spouse and the community spouse. MA Handbook, Appendix 18.4.1. All available assets owned by the couple are to be considered. Homestead property, one vehicle, and anything set aside for burial are exempt from the determination. The couple’s total non-exempt assets then are compared to an “asset allowance” to determine eligibility.
The asset allowance for this couple was set at a certain number. MA Handbook, App. 18.4.3, which is based upon Wis. Stat., §49.455(6)(b). $2,000 (the MA asset limit for the institutionalized individual) is then added to the asset allowance to determine the asset limit under spousal impoverishment policy. If the couple’s assets are at or below the determined asset limit, the institutionalized spouse is eligible for MA. If the assets exceed the above amount, as a general rule the spouse is not MA eligible.
Petitioner was found eligible for MA under the spousal impoverishment rules. Once that occurs, an important provision kicks in. The community spouse must transfer all assets to himself except for up to $2,000 which can be retained by the eligible spouse. See MA Handbook, App. 18.4.6.1. I think petitioner’s husband did not understand that requirement, and their grandson helped them after the appeal was filed. At the hearing he provided evidence that petitioner’s assets are now below $2,000 and that the rest of the funds have been put in her husband’s name. I thus will order that petitioner’s MA be continued.
If — has questions or needs other verification (in particular of property owned in Mississippi), she can follow up, but at this point I will order that eligibility remain open.
Conclusions of Law
Petitioner’s assets have been reduced below $2,000 in order to continue MA eligibility under Spousal Impoverishment rules.
THEREFORE, it is
Ordered
That the matter be remanded to the agency with instructions to continue petitioner’s MA eligibility under Spousal Impoverishment rules with assets confirmed to be below $2,000. The action shall be taken within 10 days of this decision.
[Request for a rehearing and appeal to court instructions omitted.]