MGE 216433 (03/03/2025)
Verification of asset required after a quality control review

Preliminary Recitals

Pursuant to a petition filed on December 28, 2024, under Wis. Stat. § 49.45(5), and Wis. Admin. Code HA § 3.03(1), to review a decision by the Milwaukee Enrollment Services regarding Medical Assistance (MA), a hearing was held on February 13, 2025, by telephone.

The issue for determination is whether the agency correctly terminated Petitioner’s enrollment in the Medicaid program for failure to verify her assets.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Stacy Green
Milwaukee Enrollment Services
1220 W Vliet St
Milwaukee, WI 53205

ADMINISTRATIVE LAW JUDGE:
Wendy I. Smith
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a resident of Milwaukee County who was a recent recipient of MA under the Elderly, Blind, and Disabled (EBD) Medicaid program.
2. On September 14, 2024, the agency processed an administrative renewal for Petitioner.
3. On October 28, 2024, the agency conducted a quality control review on Petitioner’s case during which it identified that Petitioner’s reported checking account/direct pay account was not fully verified. In 2023, Petitioner provided an ATM receipt as proof of the account, but this receipt does not identify the owner of the account by name.
4. In a notice dated October 29, 2024, the agency requested that Petitioner submit proof documents for her checking account/direct pay account with a due date of November 18, 2024. The notice advised that failing to provide the requested proof by the due date could result in benefits being denied, decreased, or ended.
5. Petitioner did not submit the requested proof by the stated deadline and did not contact the agency to advise that she could not obtain the information or needed assistance.
6. In a notice dated December 4, 2024, the agency advised Petitioner that her enrollment in Medicaid would end as of January 1, 2025, for not sending in proof of her assets.
7. Petitioner now appeals to the Division of Hearings and Appeals.

Discussion

SSI-related Medicaid is a health insurance program available for individuals who are elderly, blind or disabled and who meet certain other non-financial and financial eligibility criteria. Wis. Stat. § 49.47(4); see also Medicaid Eligibility Handbook (ME Handbook) § 24.1, et. seq. The agency must verify a member’s income, assets, and other information as part of the application or renewal process, and on an ongoing basis when it receives reporting of a change. ME Handbook at § 20.1, et seq. Verification of countable assets is mandatory. Id. at § 20.3.5. The agency may use all available data exchanges to verify asset information, such as through the Asset Verification System, but the member has primary responsibility for providing verification, including submitting proof information through other sources like bank statements, if necessary. Id. at §§ 20.3.5, 20.5.

The agency may deny or reduce benefits when all of the following are true:

• The applicant or member has the power to produce the verification.
• The time allowed to produce the verification has passed.
• The applicant or member has been given adequate notice of the verification required.
• The requested verification is needed to determine current eligibility. Current eligibility cannot be denied for lack of verification of a past circumstance that does not affect current eligibility.
• The member is not a child in a continuous coverage period (see Section 1.2 Continuous Coverage for Qualifying Children).

Id. at § 20.8.3.

In this case, the Respondent agency processed an administrative renewal for Petitioner and then, subsequently, conducted a quality control review of her case. During this review, the agency discovered that it never fully verified Petitioner’s assets in her reported checking account, or “direct pay” account. The agency’s representative testified at the hearing that Petitioner submitted an ATM receipt back in 2023 which was for a financial account with a negative balance, but this receipt did not include the name of the owner of the account. Petitioner had not submitted a copy of her tangible debit card to the agency. To correct this error, the agency requested by mailed notice dated October 29, 2024, that Petitioner provide proof documents for this account by November 18, 2024.

Petitioner appeared at the hearing to acknowledge that she did not submit any proof documents in response to the notice. In response, the agency terminated her enrollment as of January 1, 2025.

Based on the record, the agency was within its authority to fully verify Petitioner’s assets, as is mandatory per Medicaid program rules, in order to assess whether she remained financially eligible. Petitioner did not make any contact with the agency to advise that she could not produce the requested information or that she needed assistance. Petitioner was provided at least 20 days to respond to the verification request but failed to do so. The agency was within its authority to terminate her enrollment in the Medicaid program as a result.

I will note that Petitioner may contact the agency directly to discuss the possibility of reinstatement of benefits by providing the requested information, if she has not yet done so.

Conclusions of Law

The agency correctly terminated Petitioner’s enrollment in the Medicaid program for failure to verify her assets.

THEREFORE, it is

Ordered

That Petitioner’s appeal is dismissed.

[Request for a rehearing and appeal to court instructions omitted.]