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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
Redacted, Appellant's father
Sherry Johnson, Division of Social Services, Presenter
Stephanie Chelotti, Division of Social Services, Witness

I

Redacted (sometimes hereinafter "the appellant") challenges a decision of the Division of Social Services to terminate his Medicaid Program benefits after January 31, 2005.

DSS contends that he is ineligible based on its rule at DSSM 14100.6 because he did not keep an appointment or return an application by January 11, 2005.

The appellant contends that he did return an application form (late). He called DSS about this requirement and spoke to a temporary employee. His case is that he is diabetic and needs the support offered by the Medicaid Program to purchase diabetic supplies required to manage his illness.

II

By notice dated January 18, 2005 [Exhibit # 1] DSS proposed to terminate the appellant's Medicaid because he did not keep an appointment or return an application to renew his claim for Medicaid by January 11, 2005.

Thereafter the appellant filed a timely request for a fair hearing and asked for aid pending this hearing decision.

Despite the request, DSS did not reinstate aid as required under its rule at DSSM 5301. I directed DSS at the hearing to reinstate aid pending a final hearing decision.

The hearing was conducted on March 29, 2005 at the Lewis Building at the Department of Health and Social Services in New Castle.

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

The appellant's case for this hearing is that he is an uninsured person and has a need for treatment of diabetes. A need for a service covered by the Medicaid Program is not, by itself, a qualifying factor. Medicaid eligibility in Delaware is based largely on certain financial criteria. The appellant's uninsured status is not in dispute. This is one of several eligibility criteria which must be met for the appellant to qualify for continued coverage.

IV

Based on the testimony received for the hearing, the appellant filed a timely request for a fair hearing. DSS did not reinstate aid pending this hearing decision as required by the law. The testimony of Stephanie Chelotti is that she asked her supervisor, who is not present for this hearing, about reinstating the appellant's Medicaid and was told not to do this because the appellant's eligibility for reinstated benefits was contingent on his eligibility for Medicaid. As support for this position DSS points to the termination notice itself. [Exhibit # 1] On the last page of the notice is the statement, checked by the appellant, which reads: "I WANT to continue receiving the benefits I now receive, if eligible." [Emphasis added]

The contingent condition "if eligible" lacks any support in the rules and is at odds with the law.

The DSS rule at §5305 (1) provides that:

If a request for a hearing is filed within the timely notice period (the period between the date a notice is mailed and the effective date of the action), benefits will not be reduced or terminated pending a decision on the appeal.

This rule does not contain a provision that an appellant be eligible in order to qualify for reinstatement of aid pending a hearing decision.

The State rule implements the United States Supreme Court decision in Goldberg v. Kelly, cited herein. In Goldberg the Court stated that:

"The question for decision is whether a State which terminates public assistance . . . to a particular recipient without affording him the opportunity for a [fair hearing] prior to termination denies the recipient procedural due process in violation of the Due Process Clause of the Fourteenth Amendment."

The Court concluded that a pre-termination hearing was a constitutionally-based requirement, stating that:

"Under all the circumstances, we hold that due process requires an adequate hearing before termination of . . . benefits. . ."

Therefore, the DSS position that a recipient facing termination of benefits must be eligible for benefits in order to have them reinstated pending a fair hearing decision is, in addition to lacking a basis in logic, unlawful.

Consequently, I instructed DSS at the hearing to reinstate benefits as required under the State rules at DSSM 5301 and 5305 (1).(See Goldberg v. Kelly, United States Supreme Court, 397 U.S. 254 (1970)) This is because the appellant is entitled to a pre-termination hearing on the issues announced in the termination notice.

V

Based on the testimony received for the hearing I find that, while the appellant missed the January 11, 2005 deadline, he called DSS and spoke to an individual, probably a temporary employee, and completed a delinquent application. The testimony of Stephanie Chelotti is that she received the appellant's application renewal of January 19, 2005, one day after the termination notice was sent. The renewed application contained wage stubs. The amount of the appellant's income was entered into the DSS data base with the result that the appellant was found not to be financially eligible. As noted above, the issue of financial eligibility is not properly before me since financial eligibility is not mentioned in the termination notice that prompted the request for a fair hearing.

Under the rule at DSSM 14100.6, cited in the termination notice, a periodic review of eligibility is required. Failure to complete and return a DSS application is a ground for discontinuance of aid. However, also under §14100.6: "Medicaid coverage should not terminate without a specific determination of ineligibility."

Based on the testimony received for the hearing, the appellant did not "fail" to complete and return an application form. He misplaced the application form, called DSS to obtain another form, and returned a completed form late.

When DSS supplied the appellant with another application form at his request the agency extended the time for him to complete the redetermination.

The completed form was received on January 19, 2005, one day after DSS issued a termination notice. On January 20, 2005 DSS issued a "denial" notice. The "denial" notice was generated by the DSS automated benefit determination system which actively determines program eligibility but is not self-organizing.

The "denial" notice announces the "denial" of the appellant's "application" on the wholly different ground that the appellant's income from employment exceeds an income eligibility limit set for participation in the Medicaid Program. The factual statement in the notice that an application was denied is a misstatement of the facts of the matter.

I have not admitted the "denial" notice issued by DSS and dated January 20, 2005. This notice announces that the appellant is ineligible for continued Medicaid Program coverage because of the amount of his earnings from employment as a graphic designer with Tylaur Inc.

I have also excluded from consideration the statements and references in the DSS §5312 hearing summary to financial eligibility because the summary shifts the issue from non-renewal of a required periodic application for aid to the issue of financial eligibility, an issue not announced in the January 18, 2005 termination notice.

The issue before me for this hearing is whether the appellant's Medicaid should be discontinued because of his non-completion of a review by a deadline announced in the January 18, 2005 notice (The deadline in the notice is January 11, 2005. There is no documentary evidence offered for the hearing record that the appellant was put on notice of the January 11, 2005 deadline before the January 18, 2005 notice was given.), not the appellant's financial eligibility or ineligibility. As noted above, the action can not be sustained on this record because the appellant's missed deadline does not constitute a failure to comply as required under DSSM 14100.6. It was not an omission of performance but a tardy performance. In addition, the decision not to reinstate the appellant's benefits pending a pre-termination hearing is a denial of due process and inconsistent with the rules.

V

For the reasons given above, the decision by the Division of Social Services to deny the appellant's request for reinstatement of aid pending a pre-termination hearing is reversed.

Because of this due process violation the action is remanded to DSS for further consideration.

Date: April 1, 2005

ROGER WATERS
HEARING OFFICER

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

POSTED
RW

cc:
Redacted
Sherry Johnson for DSS

EXHIBITS

  • Exhibit # 1 (two pages) is a copy of a DSS termination notice dated January 18, 2005. This is admitted as evidence of the basis for the decision to terminate the appellant's Medicaid effective after January 31, 2005.
  • Exhibit # 2 is the appellant's request for a fair hearing and request for aid pending a hearing decision. This is admitted as evidence of a timely request for a fair hearing.
  • Exhibit # 3 (two pages) is a DSS hearing summary dated 2/14/05. This is excluded as a §5312 business record because it shifts the issue to be decided for the hearing from non-renewal of an application for Medicaid to non-eligibility for Medicaid based on the amount of the appellant's income.


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