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Decision by the Division of Social Services (DSS) to terminate medical assistance

In re: DCIS No. Redacted

Redacted, pro se, Appellant
Elizabeth Zedney, Senior Social Worker/Case Manager, Division of Social Services
Victoria Lynam, Social Worker Supervisor, Division of Social Services


Redacted ("Appellant") opposes a decision by the Division of Social Services ("DSS") to terminate his medical assistance benefits after December 31, 2004. He contends that he still qualifies for benefits because he meets one or more of the conditions listed on the closure notice. He further contends that he needs to have continued coverage of his medications for his disability.

The Division of Social Services ("DSS") contends that because the Appellant is no longer in receipt of Supplemental Security Income (SSI), he is no longer entitled to receive SSI Medicaid. In addition, the Appellant receives Medicare, and DSS has determined that he is eligible for the Qualified Medicare Beneficiary program (QMB).


By notice dated November 23, 2004, DSS proposed to terminate the Appellant's SSI Medicaid benefits after December 31, 2004. (Exhibit 3).

The Appellant filed a request for a fair hearing on December 23, 2004 and requested that benefits continue pending a hearing decision. (Exhibit 2) According to the Fair Hearing Summary (Exhibit 1) and the testimony of the parties, benefits have continued pending the DSS hearing decision.

The Appellant was notified by letter dated January 14, 2005, that a fair hearing would be held on February 17, 2005. The hearing was conducted on that date in New Castle, DE.

This is the decision resulting from that hearing.


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).1 The Medicaid Program provides support for medical services received by defined groups of low-income families and individuals. To qualify for medical support an individual must meet certain status and financial eligibility criteria. Recipients qualify for a wide range of medical services.

The Appellant received Medicaid from DSS pursuant to §17100. Section 17100 is the SSI Medicaid program. Any individual aged 65 years or over, blind, or permanently disabled (i.e. unable to engage in substantial gainful activity), receiving a benefit through the Supplemental Security Income program, is automatically eligible for Medicaid in Delaware.

In November 2004 DSS learned, through the State Data Exchange ("SDX"), that the Appellant would not receive SSI benefits after December 31, 2004 because he had Title II Social Security income in the amount of $607.00 per month. The Appellant has been enrolled in the Medicare program since February 2001. (Exhibit 5)

Since the Appellant was no longer receiving SSI, DSS proposed to close his case. However, before doing so, and in accordance with DSS regulations, DSS evaluated the Appellant's case against all of the other Medicaid programs available. In addition to other Medicaid programs, DSS administers programs for those applicants who are entitled to or are receiving Medicare, that pay all or a portion of the Medicare premium.

As a result of his $607.00 in monthly social security income, Mr. Redacted is 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. However, as a result of the Appellant's Medicaid SSI benefits being re-opened pending a hearing request, his QMB benefits have been discontinued as the Medicaid Program benefits supercede benefits Appellant would receive under the QMB program.

Mr. Redacted argues that he meets some of the conditions listed on his closure notice. (Exhibit 3) Specifically, Mr. Redacted first indicated that he fit the category of low-income, uninsured adults ages 19 through 64. DSS advised Mr. Redacted, and I find, that he is not uninsured because he has Medicare. Next Mr. Redacted raised the category of having received Section 1931 Medicaid that is now discontinued because he went to work or got a raise in his wages. When questioned, Mr. Redacted admitted that he is not working. Unfortunately, Mr. Redacted was unable to show that he met any of the alternative avenues of eligibility that would allow him to continue receiving Medicaid benefits.

The decision to terminate Medicaid benefits is, consequently, sustained on the record before me.


For these reasons, the decision of the Division of Social Services to terminate Appellant's medical assistance benefits after December 31, 2004 is AFFIRMED. DSS is instructed to re-open the Appellant's QMB case.

Date: March 19, 2005






  • EXHIBIT #1 - Copy of DSS Hearing Summary consisting of two (2) pages date-stamped January 10, 2005.
  • EXHIBIT #2 - Copy of the Appellant's request for a fair hearing date-stamped December 23, 2004, consisting of two (2) pages.
  • EXHIBIT #3 - Copy of Notice to Close Your Medical Assistance, dated November 23, 2004, consisting of four (4) pages.
  • EXHIBIT #4 - Copy of Delaware Computer Information System screen prints, consisting of five (5) pages.

1 See also, 16 Del. C. §9901.