QMB benefits normally begin on the first of the month after the month the person is determined eligible. In this case, the petitioner became eligible for Medicare in June but did not finish verification until July 5, making her benefits not start until August 1. ALJ Brian Schneider concluded there is no legal authority to backdate QMB benefits and that the agency was correct.
Note that this decision conflicts with MQB 207807, in which ALJ Peter McCombs did order backdating of QMB benefits. Also compare MQB 207494.
The attached proposed decision of the Administrative Law Judge dated September 18, 2023 is hereby adopted as the final order of the Department.
[Request for a rehearing and appeal to court instructions omitted.]Preliminary Recitals
Pursuant to a petition filed August 10, 2023, under Wis. Admin. Code, §HA 3.03(1), to review a decision by the Barron County Department of Human Services regarding the Qualified Medicare Beneficiary (QMB) program, a hearing was held on September 13, 2023, by telephone. A hearing set for August 30, 2023, was rescheduled at the petitioner’s request.
The issue for determination is whether petitioner’s QMB benefits can be backdated.
PARTIES IN INTEREST:
Petitioner:
—
Petitioner’s Representative:
Atty. Kate Schilling
Greater Wisconsin Agency on Aging Resources, Inc
1414 MacArthur Rd., Ste. A
Madison, WI 53714
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Kristen Burstad
Barron County Department of Human Services
335 E Monroe Ave
Barron, WI 54812
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Eau Claire County. Employees of Barron County and Polk County assist in handling Eau Claire County cases as part of the Great Rivers IM Consortium.
- Petitioner and her husband are farmers with relatively low income. Petitioner turned age 65 on April 9, 2023. She has been eligible for Medical Assistance (MA) since 2009.
- In late March, 2023, petitioner contacted the consortium and asked about Medicare Savings programs. She was told to call back after her Medicare started, but the worker did enter a request for the Medicare Savings program into the system. Petitioner had a number of contacts with the consortium thereafter, mostly with regard to an MA renewal but also with inquiries about QMB. She underwent ongoing verification issues while the process was ongoing.
- Petitioner had to have an appointment with the Social Security Administration to get her Medicare started. The appointment was in June, 2023. On June 30, 2023, petitioner contacted the consortium and reported that she now is eligible for Medicare Part A and B. The agency noted that there was one asset not yet verified, and petitioner provided that verification on July 5. The consortium then confirmed QMB on July 5, making petitioner eligible effective August 1, 2023.
Discussion
QMB, Special Low-Income Medicare Beneficiary (SLMB), and SLMB Plus are programs that provide assistance with Medicare Part B premiums for persons whose incomes are over the regular Medical Assistance limits. See Wis. Stat., §49.468. All three programs pay the entire Part B premium, but QMB also pays for Medicare deductibles, copayments, and coinsurance. See the MA Handbook, Appendix 32.1.1 for a full description of the programs and 32.1.3 for the benefits each pays.
Under Department policy QMB can begin on the first of the month after the month the person is determined to be eligible. Handbook, App. 32.7.1.1. Both SLMB programs can be backdated up to three months.
Petitioner argues that QMB can be backdated. She cites the SSI Program Operations Manual (POMS), §ID 00815.030. I will not include the entire quote, but the first sentence it the key: “The Social Security district/branch office should initiate the Public Welfare (PW accretion procedure) when an individual files an application for Medicare and has or will have Medicaid eligibility which will qualify them as a member of one of the State’s buy-in coverage groups.” The provision is, essentially, a direction to local SSA offices to act quickly to establish Medicare eligibility. The provision goes on to say that buy-in coverage may be retroactive based upon earlier entitlement to SSI or MA.
Wisconsin does not allow retroactive QMB eligibility. That is a Department policy that the Division of Hearings and Appeals cannot change. I reviewed both the Wisconsin Statutes and Administrative Code; they do not mention QMB start dates or retroactivity. It is possible that the QMB retroactivity prohibition is found within the Wisconsin state plan, but neither petitioner nor the county cited to it.
Petitioner makes much of the fact that petitioner had many contacts with the consortium in which she inquired about QMB. The problem is that the agency’s hands were tied; no decision on QMB could be made until Medicare eligibility was confirmed. Petitioner contacted the consortium on June 30 to confirm Medicare eligibility; at that point it was found that an asset was not fully verified (an asset that did not necessarily need to be verified for MA because petitioner had ongoing MA eligibility during the period April through July), and thus QMB was not confirmed until July 5. Under Department policy that the Division of Hearings and Appeals does not have authority to contradict, the agency correctly granted QMB effective the month after eligibility was confirmed.
Petitioner also points to an email from a Department buy-in analyst that suggests QMB could be backdated. However, no law is cited, and the analyst does not actually affirm that backdating could occur. The analyst mentions an erroneous request by SSA to have Wisconsin pay the premium beginning in April. Petitioner makes the leap that the analyst’s meaning was that the “accretion” policy should kick in, but there simply is no evidence or citation to Wisconsin using such an accretion policy. Certainly the MA Handbook does not mention such a policy. It could be that the SSA error was asking Wisconsin to start QMB in April when Medicare eligibility had not been established that early.
I conclude that, under Wisconsin’s policy, petitioner was found eligible correctly for QMB effective August 1, 2023. There simply is no Department policy, or federal law contradicting Department policy, saying that QMB can be backdated.
Conclusions of Law
The agency correctly started petitioner’s QMB eligibility effective August 1, 2023 because eligibility was not confirmed until July 5, 2023.
THEREFORE, it is
Ordered
That the petition for review is hereby dismissed.
[Notice of proposed decision omitted.]