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


In re: DCIS No. Redacted Redacted

Appearances:
Redacted, pro se, Appellant
Rosetta Apgar, Senior Social Worker/Case Manager, Division of Social Services
Victoria Lynam, Social Worker Supervisor, Division of Social Services

I.

Redacted ("Appellant") opposes a decision by the Division of Social Services ("DSS") to terminate his medical assistance benefits after September 30, 2004. He contends that because he is appealing the closure of his Supplemental Security Income ("SSI") he is entitled to continue to receive SSI Medicaid.

The Division of Social Services ("DSS") contends that because the Appellant is no longer receiving SSI, he is no longer entitled to receive SSI Medicaid, despite the fact that he may be appealing his case. In addition, the Appellant receives Medicare, and his income is over the limit to be eligible for the Qualified Medicare Beneficiary program or the Specified Low-Income Medicare Beneficiary ("SLMB") program.

II.

By notice dated September 14, 2004, DSS proposed to terminate the Appellant's Medicaid benefits after September 30, 2004. (Exhibit 3).

The Appellant filed a request for a fair hearing on September 22, 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 November 8, 2004, that a fair hearing would be held on December 6, 2004. The Appellant then requested a continuance due to a back injury. That continuance was granted and the hearing was rescheduled to and conducted on February 1, 2005 in New Castle, DE.

This is the decision resulting from that 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. 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.

On September 14, 2004, DSS learned, through the State Data Exchange ("SDX") that the Appellant was no longer receiving SSI. DSS also testified that the Appellant was not in receipt of SSI and that the testimony about this fact was not opposed. The SDX also showed that he was receiving $344.00 monthly in Title II benefits and that his spouse was receiving $1,659.08 in Worker's Compensation benefits. The Appellant is also enrolled in the Medicare program.

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.

Mr. Redacted argues that because he is appealing the decision of the Social Security Administration ("SSA") that he is entitled to continue to receive SSI Medicaid benefits. At the time of the hearing, DSS was not able to verify that Mr. Redacted was appealing the SSA ruling to discontinue his SSI benefits. In fact, DSS, through SDX, was only able to verify that Mr. Redacted was no longer receiving SSI benefits from SSA. If Mr. Redacted had been able to prove that he was not only appealing the SSA ruling, but also still receiving SSI benefits pending this alleged appeal, he would be entitled to continue to receive SSI Medicaid. In this case, there has not been credible evidence to support either the appeal of the SSA decision to discontinue his SSI benefits or the continued receipt of SSI benefit from the SSA.

The decision to terminate Medicaid benefits is sustained on the record before me. However, should the Appellant be able to show that he was both appealing the SSA decision to terminate his SSI benefits as of September 14, 2004 and that he is continuing to receive SSI benefits pending that appeal, the Hearing Officer reserves the right to re-consider this decision pursuant to DSSM §5406.1 (2).

IV.

For these reasons, the decision of the Division of Social Services to terminate Appellant's medical assistance benefits after September 30, 2004 is AFFIRMED.

Date: March 16, 2005

MICHAEL L. STEINBERG
HEARING OFFICER

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

POSTED
MLS/vmd

cc: Redacted
Rosetta Apgar, DSS
Victoria Lynam, DSS

EXHIBITS FILED IN OR FOR THE PROCEEDING

  • EXHIBIT #1 - Copy of DSS Hearing Summary consisting of two (2) pages date-stamped October 29, 2004.
  • EXHIBIT #2 - Copy of the Appellant's request for a fair hearing date-stamped September 22, 2004, consisting of one (1) page.
  • EXHIBIT #3 - Copy of Notice to Close Your Medical Assistance, dated September 14, 2004, consisting of four (4) pages.
  • EXHIBIT #4 - Copy of Delaware Computer Information System screen prints, consisting of nine (9) pages.


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