In re: DCIS No. Redacted Redacted
Redacted, Appellant's Daughter (via telephone)
Vakeesh Fawcett, Sr. Social Worker/Case Manager, Long Term Care Medicaid
Marlene Waples, Social Worker Supervisor, Division of Social Services
Redacted ("Appellant"), by and through his daughter, Redacted, applied for Medicaid Long Term Care ("LTC") and was approved as of December 2005 because DSS determined that his resources were over the $2000.00 limit in September, October and November. While the Appellant was ultimately approved for Medicaid LTC effective December 1, 2004, he was initially seeking approval as of September 9, 2004, his date of admission into Hockessin Hills.
The Division of Social Services ("DSS") contends that the Appellant's family resources limit was exceeded and therefore, his claim for Medicaid Long Term Care was not approved until December 2004, when it was determined that his resources fell below the $2,000.00 limit.
Appellant applied for Medicaid Long Term Care on October 14, 2004.
By notice dated December 16, 2004, DSS approved the Appellant's application for Medicaid Long Term Care as of December 1, 2004. (Exhibit #3) Appellant's Representative filed a request for a fair hearing on January 5, 2005, seeking to have benefits approved for October and November 2004. (Exhibit #2)
The Appellant's Representative was notified by certified letter dated February 4, 2005, that a fair hearing would be held on February 25, 2005. The hearing was conducted on that date in New Castle, DE. The Appellant's Representative testified via telephone. This is the decision resulting from that hearing.
Redacted, by and through Redacted, his daughter, applied for Medicaid Long Term Care on October 14, 2005. At that time, he was seeking coverage for his placement at Hockessin Hills beginning on September 9, 2004. Ms. Vakeesh Fawcett, his social worker, computed the family resource level based upon information she obtained from Ms. Campbell.
At the time of his application and until December 2004, the Appellant had total resources comprised of a bank account that exceeded the $2000.00 maximum allowable resource level.
Ms. Fawcett testified that when Ms. Redacted applied, she advised her that her father could not have over $2000.00 in resources and that the process of approval could take up to 90 days. Ms. Redacted testified that based upon that information, she believed that she would not be limited to having only $2000.00 in resources in her father's account until she was approved. She also testified that had she realized the $2000.00 resource limit determined the month that benefits would begin, she would have spent the money in his checking account and put all of his income into the Miller Trust that she had established in October 2004, instead of leaving his income in the checking account while awaiting approval. It was not until she received a telephone call from Ms. Vakeesh on December 1, 2004 that she understood that as soon as her father's resources were under $2000.00 he would be approved.
Ms. Fawcett further testified that in October 2004, the Appellant's bank account had a balance of $2701.07. This was followed by account balances of $3593.46 in November 2004, $4698.46 on December 3, 2004, and $1996.90 on December 10, 2004.
In computing the financial eligibility of a candidate for Medicaid Long Term Care, §20300 of the Division of Social Services Manual ("DSSM") sets a maximum allowable resource level of $2,000 for an individual. While the evidence adduced at the hearing clearly puts the Appellant's resources above that level until the middle of December 2004, the record indicates that DSS has not followed its own procedures and, as a result, has denied the Appellant the opportunity to be covered by Medicaid LTC earlier then December 1, 2004.
Pursuant to DSSM §20103.1.2 entitled, "Timely Documentation," "The DSS Medicaid worker must explain this 90-day time standard to the applicant or representative during the initial interview. It must be emphasized during the interview that all documentation needed for the worker to determine Medicaid eligibility must be received by the date indicated on the "We Need" letter (Form 415) or the application will be denied. In cases where verification is incomplete, the worker will give the applicant 15 days to return the information on the initial "We Need" letter (Form 415). The date by which all documentation must be received must be clearly noted on this form." In this case, there is simply no evidence that DSS provided a "We Need" letter to the Appellant and never denied his application for being over the resource limit, despite having determined this from the beginning.
In addition, DSSM §20300 entitled "Resources" states that, "Resources that are in effect on the first moment of the first day of a calendar month are considered as available for the entire month. The only exception to this occurs during the time of application at the beginning of a continuous period of institutionalization. In that period only, applicants will be determined eligible as of the date the resources are within the resource limit."
Likewise, there is no indication in the record that DSS ever explained to the Appellant's Representative that eligibility would be determined as of the date that the resources were within the resource limit. In fact, the testimony indicates that, based upon the statements by the social worker, the Appellant's Representative believed this could be a long process (90 days) and that knowing that she was seeking coverage starting in September or October 2004, there was no rush to move the resources until she was advised of the approval. It was not until she received a telephone call from Ms. Vakeesh on December 1, 2004 that she understood that as soon as her father's resources were under $2000.00 he would be approved. Had the information in that call been provided on the day of the interview, the Appellant may have been approved for Medicaid LTC retroactive to the date of his admission in Hockessin Hills - September 9, 2004. However, since Appellant did not meet the financial eligibility criteria during the period of September 9, 2004 through the time of his interview, the best case would be a start date of October 1, 2004. (See, DSSM §20370)
Based upon the record before me, DSS has not provided credible evidence on which to sustain its' approval of Medicaid Long Term Care for the Appellant as of December 1, 2004.
For these reasons, the decision of the Division of Social Services to approve the Appellant for Medicaid Long Term Care benefits effective December 1, 2004 is REVERSED. DSS is directed to provide Medicaid LTC benefits to the Appellant as of October 1, 2004 and make any corrective payments due Appellant pursuant to DSSM §5501.
Date: March 22, 2005
MICHAEL L. STEINBERG
THE FOREGOING IS THE FINAL DECISION OF THE DIVISION OF SOCIAL SERVICES
Vakeesh Fawcett, DSS Pool 235
Marlene Waples, DSS Pool 235
EXHIBITS FILED IN OR FOR THE PROCEEDING