Aparticipant in Institutional MA may have their patient liability reduced to allow them to pay medical or remedial expenses. In this case, the petitioner owed $22,504 in unpaid patient liability due to his brother/POA’s mismanagement, or perhaps theft (at the time of the hearing the brother was “criminally charged”), of his money. Noting that policy explicitly prohibits using unpaid patient liability or cost share for the medical/remedial expense deduction, ALJ Teresa Perez concluded the agency correctly denied the petitioner’s request to reduce his patient liability.
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed on April 18, 2025, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the La Crosse County Department of Human Services regarding Medical Assistance (MA), a hearing was held on June 4, 2025, by telephone.
The issue for determination is whether Petitioner is eligible for a reduction of his monthly patient liability to allow him to repay unpaid prior patient liability amounts.
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: Dana Lee
La Crosse County Department of Human Services
300 N. 4th Street
PO Box 4002
La Crosse, WI 54601
ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of La Crosse County who has resided at —, a skilled nursing facility, since at least July 1, 2024.
- Petitioner has been eligible for Institutional Medical Assistance since July 1, 2024.
- Petitioner’s brother, —, was Petitioner’s financial power of attorney from at least July 1, 2024 through March 2025. Throughout that time period, Petitioner had a patient liability that his brother paid only a portion of. His brother has since been criminally charged in connection with his expenditure of Petitioner’s funds.
- By April 8, 2025, Petitioner owed $22,504.56 to — as a result of his brother’s failure to fully pay Petitioner’s monthly patient liability amount from July 1, 2024 through March 2025.
- —, in its capacity as representative for Petitioner, requested the local income maintenance consortium to reduce Petitioner’s patient liability so that Petitioner could afford to enter into a payment plan to reduce his outstanding balance.
- The agency denied the request to reduce Petitioner’s patient liability because Medical Assistance program policy prohibits unpaid patient liability amounts to be used as a deductible medical expense when calculating a Medical Assistance recipient’s current patient liability.
- Petitioner filed an appeal of the agency’s denial of his request to reduce his patient liability.
Discussion
Institutionalized individuals who receive Medicaid must generally pay a “cost of care” each month. This amount is referred to as a patient liability. See Medicaid Eligibility Handbook §27.7.1.
The following amounts may be subtracted from an individual’s income when calculating the patient liability.
- $65 and ½ earned income disregard
- Monthly cost for health insurance
- Support payments
- Personal needs allowance (typically $45 per month)
- Home maintenance costs, if applicable
- Expenses for establishing and maintaining a court-ordered guardianship or protective placement, including court-ordered attorney and/or guardian fees
- Medical or remedial expenses.
Id. at 27.7.1.
Petitioner’s representative, the nursing facility where he resides, did not dispute the agency’s calculation of Petitioner’s past monthly patient liability; rather, they asked for an exception to be made given Petitioner’s unfortunate circumstances. I understand the rationale for that request. Petitioner was the victim of, at best, mismanagement of his funds and, at worst, theft. As a result, the nursing facility has not been fully compensated for the care they have provided Petitioner.
However, the agency correctly observed that Medicaid program policy explicitly prohibits the following type of expense to be used as a deduction when calculating a Medicaid recipient’s current patient liability: “a patient liability or cost share from a previous budget period, whether paid or unpaid, cannot be used as an incurred medical or remedial care expense in a subsequent budget period.” Id. at 27.7.7.2. The policy provides no exception and Petitioner did not point to any legal authority to support his request to reduce his patient liability.
As an administrative law judge, I must apply the relevant legal authority as written and reasonably interpreted and have no discretion to grant exceptions or to fashion equitable remedies, which is what Petitioner seeks here.
Conclusions of Law
The agency correctly denied Petitioner’s request to reduce his monthly patient liability to allow him to repay unpaid prior patient liability amounts.
THEREFORE, it is
Ordered
That Petitioner’s appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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