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Decision to deny application for medical assistance.


In re:
DCIS No Redacted
Redacted

Appearances:
Redacted, Claimant
Redacted, Claimant's Brother
Kristi White, Sr. Social Worker/Case Manager, Division of Social Services

I.

Redacted ("Claimant") is appealing the decision to deny his application for medical assistance.

The Division of Social Services ("DSS") contends that Claimant is not eligible for medical assistance coverage because they have determined that he is receiving insurance coverage under the Medicare program. The Claimant was opened in the Qualified Medicare Beneficiary ("QMB") program.

II.

By notice dated November 19, 2004, DSS denied the Claimant's application for medical assistance benefits. (Exhibit 3)

The Claimant filed a request for a fair hearing date-stamped December 6, 2004. (Exhibit 2)

The Claimant was notified by certified letter dated January 14, 2005, that a fair hearing would be held on February 4, 2005. A hearing was held on that date in Dover, Delaware. This is the decision resulting from that hearing.

III.

The Claimant had been living in New Jersey and receiving Medicaid. He moved to Delaware to live with his brother, Jose, and applied for medical assistance benefits. Social Worker Kristi White determined that the Claimant was receiving Medicare. When the Medicare information was entered into the computer, it caused the computer to indicate that the Claimant was technically ineligible for the Adult Poverty medical assistance program. However, the computer determined that the Claimant was eligible for the QMB program, which pays the Claimant's Medicare premium and Part A deductibles and coinsurance as well as Part B deductibles and coinsurance. (See, DSSM 17300). The Claimant was opened up in that program.

Pursuant to DSSM 16220.4, an individual must be uninsured in order to qualify and receive the medical assistance benefits sought by the Claimant. An uninsured individual is defined as an individual who does not have Medicare, CHAMPUS, or other comprehensive health insurance. In this case, because Claimant is receiving Medicare he is technically ineligible for Adult Poverty medical assistance benefits.

IV.

For these reasons, the decision of the Division of Social Services to deny Claimant's Medical Assistance application is AFFIRMED.

Date: March 15, 2005

MICHAEL L. STEINBERG
HEARING OFFICER

THE FOREGOING IS THE FINAL DECISION OF THE DIVISION OF SOCIAL SERVICES

POSTED
MLS/vmd

cc:
Redacted
Kristi White, Pool 360

EXHIBITS FILED IN OR FOR THE PROCEEDING

  • EXHIBIT #1 - Copy of DSS Hearing Summary consisting of two pages, date-stamped December 9, 2004.
  • EXHIBIT #2 - Copy of Claimant's request for a fair hearing dated December 6, 2004, consisting of one (1) page.
  • EXHIBIT #3 - Copy of Notice to Deny Your Medical Assistance dated November 19, 2004 consisting of two (2) pages.
  • EXHIBIT #4 - Copy of Notice to Approve Your Medical Assistance dated November 19, 2004 consisting of three (3) pages.


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