Income Maintenance agencies must assist Medicaid applicants and members with verification if asked or if they have difficulty in obtaining it. In this case, the petitioner—a 72-year old woman—faxed the required verification of her life insurance, but a faxing error caused the agency to receive an incomplete copy. She then called the agency to follow up and was told the verification was not received. ALJ Kenneth Duren concluded this was a request for assistance and the agency should have helped, and ordered her QMB benefits restored as if she had provided the verification timely.
This decision was published with support from the Elder Law & Special Needs Section of the State Bar of Wisconsin and the Wisconsin chapter of the National Academy of Elder Law Attorneys.
Preliminary Recitals
Pursuant to a petition filed on February 23, 2024, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Milwaukee Enrollment Services regarding the discontinuance of Medical Assistance (MA) – Qualified Medicare Beneficiary premiums, a hearing was held on March 28, 2024, by telephone.
The issue for determination is whether the Department correctly discontinued the petitioner’s Qualified Medicare Beneficiary eligibility effective February 2024, due to a failure to verify her life insurance policy timely.
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: Princeton Perry, ESS
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, WI 53205
ADMINISTRATIVE LAW JUDGE:
Kenneth D. Duren
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Milwaukee County. She was receiving coverage of her federal Medicare premiums under the Qualified Medicare Beneficiary (“QMB”) program in at least December 2023.
- The petitioner completed a renewal application for Medical Assistance (MA) – Community Waivers and attached Qualified Medicare Beneficiary (“QMB”) eligibility on or about December 19, 2023; a decision on the application was pended on December 20, 2023, as the agency needed more information from the petitioner.
- On December 21, 2023, a verification request letter was sent to the petitioner seeking verification of a life insurance policy; the due date was January 9, 2024.
- On or about December 21, 2023, the petitioner faxed the verification information to the agency; but the agency did not get a complete copy, apparently due to a fax machine error.
- On December 29, 2023, the petitioner called to agency to see if her verification document had been received; she was told it had not.
- On January 9, 2024, the life insurance policy verification was still not received, and the agency acted to discontinue the petitioner’s MA, effective March 1, 2024.
- On January 10, 2024, a notice was issued discontinuing MA, apparently effective February 1, 2024, due to a failure to verify information requested.
- On February 5, 2024, the petitioner again contacted the agency to see if her verification materials had been received.
- On February 6, 2024, the agency processed the missing life insurance policy verification, and the petitioner’s MA – QMB premium benefits eligibility was re-opened effective March 2024, but her January 2024, QMB was interrupted, and this caused the federal agency to take the cost of the premium for February 2024, from her Social Security benefits. (She stated that this was an amount of $174.70 at the hearing.)
- On February 7, 2024, the agency sent a positive notice to the petitioner informing her that her QMB eligibility had been granted effective March 1, 2024.
- On February 24, 2024, the petitioner filed an appeal with the Division of Hearings & Appeals contesting the discontinuance of her QMB eligibility effective February 1, 2024, and asserting that she had verified the life insurance policy information. Her discontinued Medical Assistance Community Waivers benefits were similarly interrupted; she also appealed that; and the MA discontinuance issue was reviewed in the companion case decision, DHA Case No. MGE-212319.
- The petitioner’s QMB benefits were apparently not continued pending the hearing. Her eligibility has been restored prospectively by the agency, beginning March 1, 2024. See, Finding of Fact #10, above.
Discussion
As in the companion case referenced in Finding of Fact #12, above, I am satisfied that the petitioner did timely verify her life insurance policy information by the due date of January 9, 2024, but the verification received was incomplete due to circumstances beyond her control. When the petitioner contacted the agency on December 29, 2023, and reported that she had faxed in the simple one item verification information and inquired whether the agency had it (and was it sufficient), I take that as a request for assistance with problematic verification from a 72 year-old citizen. Medicaid Eligibility Handbook, § 20.1.4. The agency should have assisted her in the transfer of this simple verification. This situation should not have risen to the level of taking two months to complete the verification process, nor a fair hearing. In addition, the elderly citizen’s Qualified Medicare Beneficiary was stopped, and she lost one month’s premium from her precious monthly cash benefit as a result, according to her testimony.
The discontinuance of the petitioner’s QMB effective February 1, 2024, must be reversed, and her QMB eligibility restored retroactive to February 1, 2024, as if she had timely verified her insurance policy on December 29, 2023.
As a sidenote to the petitioner, QMB premiums are taken under an elaborate federal-state data match system that occurs systemically and periodically and involves the benefits data of thousands of citizens. It will undoubtedly take some time for her single premium taken for February 2024, to be identified and refunded to her. She would be well-advised to monitor her Social Security benefits, statements, and notices for the next 2-3 months, to ensure the refund occurs. She may also desire to submit a copy of this decision as a point of information, to the SSA. I have no authority over the federal agency directly, however; only the state/county MA agency. Finally, she would be well-served to remind the county agency in the coming weeks that she is expecting a QMB refund for February 2024. I note also that in general, when I have had occasion to frame such an ORDER as this about past QMB premiums incorrectly taken, it has been carried out successfully.
The agency is expected to cooperate fully in effectuating this refund of the February (only) 2024 QMB premium erroneously taken from the petitioner’s SSA benefits.
Conclusions of Law
That the county agency incorrectly discontinued the petitioner’s QMB premium benefit effective February 1, 2024, resulting in her loss of the benefit and taking of her Medicare premium as cash from her SSA benefits for February 2024, alone, due to a verification deficit; she timely verified on or about December 29, 2023.
THEREFORE, it is
Ordered
That the matter is remanded to the Department’s MilES agency with instructions to: take all actions necessary to reverse and rescind the discontinuance of the petitioner’s Qualified Medicare Benefits premium eligibility effective February 1, 2024; restore her eligibility for QMB benefits for the premium month of February, 2024, with written Notice; and issue the requisite date/notification to the Social Security Administration to direct the premium paid by her for her otherwise covered February, 2024, Medicare premium to be refunded to her. These State agency actions shall be completed within 10 days of the date of this decision, concluding with direction SSA to refund the February premium.
[Request for a rehearing and appeal to court instructions omitted.]