MGE 217686 (06/17/2025)
Month application was reopened determined backdating

Preliminary Recitals

Pursuant to a petition filed on March 27, 2025, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Brown County Human Services regarding Medical Assistance (MA), a hearing was held on May 14, 2025, by telephone.

The issue for determination is whether the petitioner’s Institutional Medicaid should be backdated to October 1, 2024.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Petitioner’s Representative:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Nicole Kurth
Brown County Human Services
Economic Support—2nd Floor
111 N. Jefferson St.
Green Bay, WI 54301

ADMINISTRATIVE LAW JUDGE:
Kate J. Schilling
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a 76 year old resident of Brown County. He has been a resident at the — (hereafter “—”) since 2019. He was open for Institutional Medicaid from May 2020 through June 30, 2024.
2. On June 26, 2024, the petitioner’s daughter and authorized representative called the agency to complete her father’s annual Medicaid renewal. The agency sent out a request for verification of bank accounts, pension information, life insurance policy, and the — resident account. The due date for the verification was July 16, 2024.
3. On July 16, 2024, the agency had not yet received the verification documents, so it extended the due date to July 26, 2024.
4. On or about July 18, 2024, the petitioner’s Medicaid application was denied due to being over the $2,000 asset limit.
5. On September 27, 2024, a new Medicaid application was submitted to the agency, along with bank statements from July, August and September, as well as the resident account balance statement from —.
6. On October 15, 2024, — called the consortium and was informed that the case was still pending for verification of the petitioner’s pension and life insurance policy. It was also noted that the application required a spousal signature as the petitioner was married.
7. On October 28, 2024, the authorized representative called the agency to request an extension on the outstanding verification items. The agency approved an extension until November 7, 2024.
8. On November 7, 2024, the agency denied the Medicaid application for failure to provide verification of the life insurance policy, pension, and a spousal signature.
9. On November 11, 2024, the petitioner’s representative provided verification to the agency of one of the two pensions. The agency reopened the case and sent out a request for the outstanding verifications, due by December 11, 2024.
10. On December 11, 2024, the petitioner’s Medicaid was denied due to failure to verify the second pension.
11. On December 12, 2024, — called the agency to find out if any other verifications were needed. The agency stated that it had verification of one pension, but not the other. The agency representative provided contact information for possible assistance obtaining the second pension verification. The agency also stated that it needed the spousal signature.
12. On December 18, 2024, the agency received verification of the petitioner’s second pension.
13. On December 24, 2024, — submitted a request for undue hardship to the agency as the petitioner was not in contact with his estranged spouse.
14. On January 6, 2025, the agency advised — that the petitioner had to submit a new application.
15. On January 10, 2025, the agency received a new signature page of the Medicaid application. The agency reactivated the case and requested current bank statement verification with a due date of February 10, 2025.
16. On February 10, 2025, the Medicaid application was again denied for failure to provide verifications.
17. On February 19, 2025, the authorized representative re-requested Medicaid benefits with a three month backdate. The agency sent out a request for asset verification, due by March 21, 2025.
18. On March 5, 2025, all verifications were provided to the agency and the undue hardship wavier for lack of a spousal signature was approved. The agency sent out a notice that the petitioner was approved for backdated Medicaid as of November 1, 2024.

Discussion

To be eligible for “Elder / Blind / Disabled Medicaid” (“EBD Medicaid”), a category that includes “Nursing Home Long Term Care” (also referred to as “Institutional Medical Assistance”), an unmarried individual must meet certain financial eligibility requirements. The countable asset limit for Institutional Medical Assistance, sometimes referred to as nursing home long term care, is $2,000 for an unmarried individual. Medicaid Eligibility Handbook (MA Handbook) §§27.5.1 and 39.4.1. Asset amounts are determined as of the last day of the month.

Assets
A person’s asset eligibility in a backdate month is determined by whether or not he or she had excess assets on the last day of the month. If he or she had excess assets on the last day of the month, he or she is ineligible for the entire month. If he or she was asset eligible on the last day of the month, he or she is eligible for the whole month.

MA Handbook §2.8.2. Medicaid can be backdated up to three months prior to the date of the application if the applicant would have been eligible for benefits had they applied in that month. MA Handbook §2.8.2. In this case, the petitioner lost Medicaid eligibility in July 2024 due to failure to submit verifications following his June renewal. The petitioner’s daughter and — realized that the petitioner was over the Medicaid asset limit at the end of July due to a missed monthly patient liability payment which caused his assets to accumulate over $2,000. The agency denied the petitioner’s Medicaid eligibility on or about July 18, 2024, due to being over the asset limit.

In early September, the facility reached out to the IM agency to find out the status of the petitioner’s Medicaid eligibility. The facility was informed that the petitioner would need to submit a new application for Medicaid as the case had been denied in July 2024. On September 30, the facility submitted a new Medicaid application as well as bank account statements for July, August, and September 2024 to the IM agency. The agency pended the case for verification of the petitioner’s life insurance policy, two pensions, and a spousal signature since he was married. These verifications were due by October 28, 2024; however, upon the petitioner’s daughter’s request, the agency extended this deadline to November 7, 2024. The application was denied on November 7, 2024, due to failure to provide the required verifications. On November 11, 2024, the agency received verification regarding one of the petitioner’s two pensions. The agency reopened the case and sent out a new request for verification of the outstanding items, with verifications due on December 11, 2024.

On December 18, 2024, the agency received verification of the second pension. On December 24, 2024, the facility submitted the request for an undue hardship waiver of the spousal signature as the petitioner was separated and did not have contact information for his estranged spouse. The agency agreed to hold onto the undue hardship application until all of the verification items had been provided, and then to make a determination at that point. On January 10, 2025, the agency received an updated signature page of the EBD Medicaid application. It reopened the case and pended the case for verification of the petitioner’s bank accounts, due on February 10, 2025. The verifications were not received by that deadline, so the agency denied the application. On February 19, 2025, the agency reopened the case at the request of the petitioner’s representative, with verifications due by March 21, 2025. On March 5, 2025, the agency received all necessary verifications and approved the petitioner’s request for a hardship waiver. The petitioner was approved for Institutional Medicaid with a backdate to November 1, 2024.

The facility argued at the hearing that the petitioner’s Medicaid should have been backdated at least to October 1, 2024, since it had submitted a Medicaid application in January 2025. However, that application was denied on February 10, 2025 due to lack of verification. The facility requested that the application be re-opened on February 19, 2025, and verifications were ultimately provided by the deadline set by the agency. Given this timeline, the agency correctly considered it as an application in February 2025, with a request for a three month backdate going to November 1, 2024.

The IM agency did not receive all requested verification documents until March 5, 2025. The petitioner had at least three different bank accounts, two pensions, a life insurance policy, and a resident account at the facility. That created a lot of work for the facility and petitioner’s daughter to obtain verification for the Medicaid renewal. Additionally, the petitioner’s daughter was hospitalized for a period of time and unable to help with the application and verification process.

The facility raised the issue that the agency failed to mention that a new application would be required to reapply for Medicaid in January 2025. However, in reading the extensive case notes from the agency over the past year, I see that the agency responded timely to the inquiries from the facility and the petitioner’s daughter. It re-opened the Medicaid applications repeatedly when verifications were submitted after the stated deadlines, and it processed the documents submitted by the petitioner’s representatives in a timely manner. When the facility informed the agency that it was having difficulty obtaining verification of the second pension, the agency representative looked back in the case file archives to find previously submitted documentation of that pension, and provided the contact information to the facility staff. Finally, the agency processed and approved the undue hardship waiver for lack of a spousal signature almost immediately after receiving the final outstanding verifications.

The staff from the facility were diligent about following up on requests for verification of the petitioner’s income and assets. However, many of the verifications were submitted to the agency just after the deadline. This caused the Medicaid application to be denied and delayed the process. According to the MA Handbook § 20.5, the applicant has the primary responsibility to provide verification to the agency. In this particular case, the verification process was more arduous as the petitioner had three bank accounts, two pensions, a life insurance policy, and a resident account. Moreover, the petitioner had an estranged spouse not involved with the Medicaid application, which then required the approval of an undue hardship waiver. These factors all led to it taking longer for the Medicaid application and required verification documents to be obtained and submitted. However, given that there was no significant agency error or delay, as well as the fact that the petitioner did not submit all of the required verification documents until March 5, 2025, I cannot adjust the petitioner’s Medicaid start date.

Conclusions of Law

The agency correctly processed the petitioner’s Medicaid application with a backdate to November 1, 2024.

THEREFORE, it is

Ordered

The petition for review is hereby dismissed.