State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave.

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1 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 Rocco S. Fucillo Cabinet Secretary January 16, , Esq RE: ---- v. WVDHHR ACTION NO.: 12-BOR-2376 Dear Mr. ----: 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. If you believe the decision was reached in error, you may appeal. See the attached explanation of Claimant s Recourse. Sincerely, Pamela L. Hinzman State Hearing Officer Member, State Board of Review cc: Erika H. Young, Chairman, Board of Review ----, Esq., ---- Paula Salcedo, WVDHHR

2 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BOARD OF REVIEW IN RE: , Claimant, v. ACTION NO. : 12-BOR-2376 WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES, Respondent. DECISION OF STATE HEARING OFFICER I. INTRODUCTION: This is a report of the State Hearing Officer resulting from a fair hearing for This hearing was held in accordance with the provisions found in the Common Chapters Manual, Chapter 700 of the West Virginia Department of Health and Human Resources. This fair hearing was convened telephonically on January 2, 2013, on a timely appeal filed October 10, 2012, and received by the Hearing Officer on November 13, The hearing record remained open until January 9, 2013, for the submission of written closing statements from the Claimant s legal counsel. A Post-Hearing Brief was submitted to the Hearing Officer by the Claimant s counsel on January 7, The Department declined the opportunity to submit a closing statement. All persons giving testimony were placed under oath. II. PROGRAM PURPOSE: The program entitled Long-Term Care Medicaid (nursing facility services) is a medical service which is covered by the State s Medicaid Program. Payment for care is made to nursing homes which meet Title XIX (Medicaid) standards for the care provided to eligible recipients. In order to qualify for Nursing Home Care, an individual must meet financial and medical eligibility criteria. III. PARTICIPANTS: ----, Esq., ----, Counsel for the Claimant and , Esq., ----, Counsel for the Claimant and

3 ----, Administrator, , Area Medicaid Manager, , Accounts Receivable Coordinator, ---- Paula Salcedo, Economic Service Worker, WVDHHR Margie Woods, Economic Service Worker, WVDHHR Belinda Nelson, Operations Supervisor, WVDHHR Presiding at the hearing was Pamela L. Hinzman, State Hearing Officer and a member of the State Board of Review. IV. QUESTION TO BE DECIDED: The question to be decided is whether the Department received a Long-Term Care Medicaid application for the Claimant in August V. APPLICABLE POLICY: West Virginia Income Maintenance Manual Chapters 1.2.C.1, 1.22.C and 17.2.A VI. LISTING OF DOCUMENTARY EVIDENCE ADMITTED: Department s Exhibits: D-1 Copy of Long-Term Care Medicaid application for received by Department on April 10, 2012 D-2 Letter sent to Claimant on May 11, 2012, requesting verification of assets D-3 Copies of bank account information provided by Claimant D-4 Notices of Decision dated June 29, 2012 D-5 West Virginia Income Maintenance Manual Chapters and J11.3 D-6 Request for appeal and remedial Medicaid D-7 Written statement of ----dated January 2, 2013 Claimant s Exhibits: C-1 Pre-Hearing Brief C-2 Authorization Statement and Assignment Provision C-3 Resident Admission and Financial Agreements C-4 Medicaid application signed by (date signed, August 10, 2012) VII. FINDINGS OF FACT: 1) The Claimant, a 56-year-old disabled man, was admitted to ----on November 7, ) Paula Salcedo, an Economic Service (Long-Term Care Medicaid) Worker (ESW) with the West Virginia Department of Health and Human Resources, hereinafter Department, testified that the Claimant s mother applied for Long-Term Care Medicaid benefits on the Claimant s behalf on April 10, 2012 (see Exhibit D-1). The Department sent the Claimant a letter on May 11, 2012 (D-2), requesting verification of his savings account balance for the - 2 -

4 months of January 2012, February 2012, March 2012 and April The requested information (D-3) was subsequently received by the Department. 3) The Department sent the Claimant Notices of Decision (D-4) on June 29, 2012, indicating that he had been approved for Long-Term Care Medicaid for the period of January 2012 through March ESW Salcedo testified that the Claimant was denied ongoing Medicaid benefits because his assets were excessive in April ) ESW Salcedo testified that she received a letter from ----, PLLC, in October 2012 (D-6), requesting remedial Medicaid benefits for February 2012 and June She indicated that the Claimant did not owe a resource contribution for the approved months (January March 2012) and no subsequent Long-Term Care Medicaid applications had been submitted on the Claimant s behalf. Belinda Nelson, Operations Supervisor for the Department s ---- District office, was present at the hearing and provided a written statement (D-7), indicating that she searched all mail logs at the office for the year 2012, and found no record of the Department having received a Medicaid application for the Claimant during the month of August Ms. Nelson testified that hand-delivered information brought into the office is taken by a worker and logged into the Department s computer system. The information is then distributed to the appropriate worker for processing and is later logged into the computer as being complete. Ms. Nelson stated there is very little chance that an application could be lost in the office based on the log-in system. Margie Woods, Economic Service Worker with the Department, indicated that incoming applications have at times been misplaced and assigned to the incorrect worker, but she could recall no circumstance in which an application had circumvented the log-in procedure. ESW Woods indicated that the Claimant s case file was searched to ensure that the application was not accidentally filed, however no application for August 2012 was located. 5) ----, Area Medicaid Manager for ----, testified that she reviewed the Claimant s case and contacted ESW Salcedo regarding the Claimant s Long-Term Care Medicaid application. She indicated that ESW Salcedo told her the Claimant s Medicaid application had been denied for April 2012 due to excessive assets. Ms stated that ESW Salcedo advised her to submit a new application, which Ms contended was completed in August Ms testified that she asked ----Accounts Receivable Coordinator ---- to contact the Claimant s mother to review and sign the application (C-4), and to have the application hand-delivered to the Department for processing. It should be noted that Exhibit C-4 was signed by the Claimant s mother on August 10, 2012; however there is no Department datestamp to verify that it was received in the Department s ---- District office testified that she normally comes into the ---- District office and personally date-stamps both her copy and the Department s copy of Long-Term Care Medicaid applications, places them in separate folders for either ESW Salcedo or ESW Woods, and gives them to the front desk clerk. She indicated that four applications she delivered to the Department had been distributed to the wrong unit; however, they were later located. ESW Salcedo testified that it is not normal office procedure for individuals delivering applications to date-stamp their own forms at the Department later indicated that she did not date-stamp the Claimant s application in August 2012 because another individual had delivered it to the Department. ----, Administrator at ----, testified that Medicaid had continued to pay for the Claimant s care, so the nursing home had no reason to believe his coverage was interrupted

5 6) West Virginia Income Maintenance Manual Chapter 17.2.A states: The application process for payment for nursing facility services is the same as the application process for the appropriate coverage group outlined in Chapter 1 with the following exceptions: 1. When the Department Participates in Payment The Department participates in the payment of nursing facility services when it is established that: The patient is Medicaid eligible or, if he must meet a spenddown, the monthly spenddown amount is equal to or less than the facility s monthly Medicaid rate. Nursing facility care is medically necessary. He is receiving care in a certified and Departmentapproved nursing facility. 2. Date of Eligibility Payment for nursing facility services begins on the earliest date the three following conditions are met simultaneously: - The client is eligible for Medicaid; and NOTE: If the client is eligible as an SSI-Related Medicaid client, his monthly spenddown is presumed to be met when the cost of his nursing facility care at the Medicaid rate exceeds his spenddown amount. Thus, his Medicaid eligibility begins the first day of the month of application or the first day of the month, up to 3 months prior to the month of application, when coverage is backdated. - The client resides in a Medicaid-certified nursing facility; and - There is a valid PAS or, for backdating purposes only, physician s progress notes or orders in the client s medical records. 7) West Virginia Income Maintenance Manual Chapter 1.22.C provides the following information concerning the application date for SSI-Related Medicaid (including Long- Term Care Medicaid) groups: - 4 -

6 The date of application is the date the applicant submits a DFA-2 or DFA-MA-1, in person, by fax or other electronic transmission or by mail, which contains, at a minimum, his name and address and signature. When the application is submitted by mail or fax, the date of application is the date that the form with the name, address and signature is received in the local office. 8) West Virginia Income Maintenance Manual Chapter 1.2.C.1 states: APPLICATION REGISTER AND OTHER COUNTY CONTROLS 1. Application Register Each local office must maintain a register of applications on Form DFA-15, Application Log, or a similar method, containing at a minimum, the same information on the DFA-15. The office may choose to have the application register maintained for the entire office or for each WV WORKS or Income Maintenance unit. If retained by each unit, copies of the registers must be compiled at the end of each month and stored together in one location. VIII. CONCLUSIONS OF LAW: 1) Policy states that the date of application for SSI-Related Medicaid (including Long-Term Care Medicaid) is the date the applicant submits a DFA-2 or DFA-MA-1, in person, by fax or other electronic transmission or by mail, which contains, at a minimum, his name, address and signature. When the application is submitted by mail or fax, the date of application is the date that the form with the name, address and signature is received in the local office. Each local office must maintain a register of applications on Form DFA-15, Application Log, or by a similar method. 2) While the Claimant s representatives provided a Long-Term Care Medicaid application - signed by the Claimant s mother on August 10, there is no evidence to demonstrate that the application was actually submitted to the Department in August Information provided during the hearing indicates that Department representatives have no record on mail/office logs - of having received a Medicaid application for the Claimant in August 2012, and the application provided by the Claimant s representatives bears no Department date-stamp to verify submission. IX. DECISION: It is the decision of the State Hearing Officer to uphold the Department s position that it received no Long-Term Care Medicaid application for the Claimant in August

7 X. RIGHT OF APPEAL: See Attachment XI. ATTACHMENTS: The Claimant s Recourse to Hearing Decision Form IG-BR-29 ENTERED this 16th Day of January Pamela L. Hinzman State Hearing Officer - 6 -

State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave.

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 October 5, 2012 Rocco S. Fucillo