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Decision of the Division of Social Services to discontinue Medicaid Program benefits.


In re: DCIS No.: Redacted Redacted

Appearances:
Redacted pro se, Appellant
Megan Reynolds, Senior Social Worker/Case Manager, Division of Social Services, Declarant

I

Redacted (sometimes hereinafter "the appellant") challenges a decision of the Division of Social Services (sometimes herein "the Division" or "DSS") to discontinue his Medicaid Program benefits after February 28, 2005. He contends that the Division should take into account his work related and other expenses such as a Court ordered child support wage deduction in its determination of eligibility.

DSS contends that it reached its decision based on wage stubs that the appellant provided for a periodic review of eligibility and that his income exceeds the eligibility limit set for participation in the Delaware Medicaid Program.

II

By notice dated February 16, 2005 DSS announced the termination of the appellant's Medicaid Program coverage after February 28, 2005.

The appellant filed a timely request for a fair hearing on February 28, 2005. His request asks for reinstatement of benefits pending a pre-termination hearing.

Despite this request DSS did not reinstate benefits as required by operation of its rule at DSSM 5301.

The hearing was conducted at the Lewis Building in New Castle on March 21, 2005.

This is the decision resulting from the hearing.

III

The Division of Social Services of the Department of Health and Social Services operates the Medicaid Program under Title XIX of the federal Social Security Act and under the authority it derives from 31 Del. C. §502(5), §503 (b), and §505 (3). The Medicaid Program provides support for medical services received by defined groups of low-income families and individuals. Persons who meet income and status eligibility tests, such as age, citizenship, and residency, may participate in the program. Participants qualify for payment for a wide range of medical services.

The essential facts in this matter are not in dispute. The appellant is employed by All Star Cleaning Co. and works at Our Lady of Fatima School in New Castle. He is paid $7.50 per hour and works approximately 30 hours per week. In February 2005 DSS eligibility worker Meagan Reynolds determined, following a periodic review of eligibility, that he would be paid $889 (gross) in March 2005. The DSS automated eligibility determination system found that this amount of income less a $90 per month standard deduction for wage earners exceeded an income eligibility limit of $776 per month and proposed to terminate the appellant's Medicaid benefit after February 2005.

Thereafter, the appellant filed a timely request for a fair hearing. DSS did not reinstate aid pending this hearing decision as required by the law and, at the hearing, I instructed the DSS declarant to reinstate benefits pending this hearing decision as required under the State rules at DSSM 5301 and 5305 (1).

The appellant receives aid pursuant to DSSM 16110. This is a demonstration Medicaid Program that provides aid to, inter alia, low income uninsured individuals.

His case for the hearing is that his wages vary in amount, that the DSS decision did not take into account his obligation to pay child support (which is deducted from his wages apparently by Court order) or the cost of his work-related transportation.

I have reviewed the Medicaid Program rules. These necessary costs and obligations are not factors in the determination of Medicaid Program eligibility in Delaware.

The appellant also asserts that he is harmed by the action because he will have to pay "for a part of [his] depression drug." This is apparently a reference to a proposed co-payment for prescription drugs under the Delaware Medicaid Program. This is not relevant to the action under appeal, in part because the proposed action has not been given effect.

Based on the documentary and testimonial evidence received for the hearing, I find that the appellant's average gross income, as determined from wage stubs that he provided to DSS (Exhibit # 4) exceeded an income eligibility limit of $799. DSS averaged the weekly gross pay and converted it to monthly income using a conversion factor of 4.33 as authorized by operation of the DSS rule at DSSM 16230. The DSS declarant testified at the hearing that this limit was changed to $798 per month.

I reviewed DSS Administrative Notice A-06-2005. The change in the income eligibility limit to $798 per month (or $9,570 per year) was effective on February 1, 2005. Therefore, the limit quoted in the termination notice dated February 16, 2005 is in error. The automated benefit determination system termination notice does not comply with the DSS rule at DSSM 5301 (4) (d) because it does not state "the relevant eligibility limits." It states the limit in effect before the action announced in the February 16, 2005 notice.

IV

Because the February 16, 2005 termination notice does not put the appellant on notice of the applicable income eligibility limit in effect at the time of the action the notice announces, it is legally insufficient to give effect to the proposed termination.

Consequently, the decision to terminate the appellant's Medicaid after February 28, 2005 is reversed and remanded. DSS is directed to reconsider the appellant's financial eligibility for Medicaid and, if the agency finds that he is not eligible, to issue a notice that complies with DSSM 5301.

Date: March 24, 2005

ROGER WATERS
HEARING OFFICER

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

POSTED
RW

Cc:
Redacted
Megan Reynolds, for DSS

EXHIBITS

  • Exhibit # 1 (four pages) is a copy of a DSS Medicaid Program termination notice dated February 16, 2005.
  • Exhibit # 2 one page, two-sided, is the appellant's request for a fair hearing. This is admitted as evidence of a timely request for a fair hearing.
  • Exhibit # 3 is a §5312 hearing summary dated March 4, 2005.
  • Exhibit # 4 consists of photocopies of the appellant's wage stubs from All Star Cleaning Co. for dates including December 30, 2004, January 6, 2005, January 12, 2005, and January 19, 2005. These are admitted as evidence of information used by DSS to determine the amount of the appellant's earned income.
  • Appendix "A" (two pages) consists of photocopies of six the appellant's wage stubs from dates in January, February and March 2005. These are not admitted for relevance since they are not for the same time period covered by this action.


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