MGE 218599 (08/15/2025)
Missed nursing home payment put petitioner over assets

Preliminary Recitals

Pursuant to a petition filed on June 2, 2025, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Dunn County Department of Human Services regarding Medical Assistance (MA), a hearing was held on July 23, 2025, by telephone.

The issue for determination is whether the petitioner is entitled to backdated long-term care Medicaid for the month of February 2025.

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: Kristen Burstad
Dunn County Department of Human Services
808 Main Street
PO Box 470
Menomonie, WI 54751

ADMINISTRATIVE LAW JUDGE:
Peter McCombs
Division of Hearings and Appeals

Findings of Fact

1. Petitioner (CARES # —) is a resident of —, located in Superior, Wisconsin.
2. On April 14, 2025, petitioner’s healthcare application was denied for being over the asset limit for the MA program. On April 22, 2025, a re-request was submitted by petitioner’s son and Power of Attorney, —, with the indication that excess funds were used to pay the nursing home and that petitioner was now below the asset limit. On April 25, 2025, verification was received and processed, and eligibility was confirmed open as of April 1, 2025, for Institutional Medicaid.
3. Upon review of the case at the time of the denial of January, February and March eligibility, the respondent had found the following: the countable assets for January of 2025 were $9,265.04 ($339.40 in money market account — & $8,925.64 in checking account —). The countable assets for February of 2025 were $12,119.19 ($550.40 in the money market account & $11,568.79 in the checking account). The countable assets for March of 2025 were $13,733.07 ($664.79 in the money market account & $13,068.28 in the checking).
4. On June 2, 2025, — filed an appeal with the Wisconsin Division of Hearings and Appeals regarding the denial of Institutional Medicaid for petitioner for the months of January, February and March of 2025.
5. The respondent reviewed this matter prior to hearing and updated the case with further financial information. On July 14, 2025, petitioner was notified that her enrollment in Institutional MA for the months of January 2025 and March 2025 was certified with a patient liability of $2,586.45 for each of the months. On that same date petitioner was notified that her February MA case remained denied for being over the asset limit.
6. At hearing, petitioner’s son testified that the excess assets held in petitioner’s accounts in February 2025, stemmed from an inadvertent error in timely submitting a payment to petitioner’s care facility that month. Petitioner’s son paid the balance due in March of 2025.

Discussion

Medicaid is a state/federal program that provides health coverage for Wisconsin residents that are elderly, blind, or disabled (EBD) or receive Wisconsin Well Woman Medicaid. Medicaid is also known as Medical Assistance, MA, and Title 19. The EBD fiscal group’s assets must be within the appropriate categorically needy or medically needy asset limit before any member of that group can qualify for Medicaid. EBD fiscal groups who have assets in excess of the appropriate EBD medically needy asset limit are ineligible for Medicaid. See Medicaid Eligibility Handbook (MA Handbook) §§1.1.1 and 1.1.3.1., available online at http://www.emhandbooks.wi.gov/meh-ebd/.

An individual is financially eligible for EBD Medicaid if the total value of all non-exempt liquid assets does not exceed $2,000. Wis. Stats. §49.47(4)(b). The clear, unambiguous language of both Wis. Stat. §49.47(4)(b), and Wis. Admin. Code §DHS 103.08(1), states that eligibility cannot exist prior to the date on which all eligibility requirements are met. Until the actual date that an individual’s liquid assets fall below $2,000, an individual is ineligible for Medicaid.

Generally speaking, a home, one vehicle, Medicaid-compliant burial assets, and personal belongings are exempt assets and do not count towards the asset limit. Life insurance policies are countable assets when the total face value exceeds $1,500. MA Handbook §16.7.5. Most other assets, including savings and checking bank accounts, are countable assets. MA Handbook §§ 16.1 and 16.7. Medicaid policy is that asset eligibility is determined on the last day of the month.

If he or she was asset eligible on the last day of the month, he or she is eligible for the whole month.

Medicaid Eligibility Handbook § 2.8.2. In reviewing this matter after petitioner’s appeal was filed by contacting the petitioner’s funeral home and nursing facility, the respondent was able to verify that payments made on petitioner’s behalf resulted in eligibility compliance for the months of January and March of 2025. Unfortunately, the failure to pay the petitioner’s facility in the month of February left assets in her account that resulted in a balance exceeding MA program limits.

The petitioner’s son is her power of attorney for finances, and he handles his mother’s bill payments as she is unable to do so herself. He testified credibly regarding his efforts to maintain compliance with MA eligibility requirements, and conceded that he inadvertently missed a payment to the facility in February 2025, which resulted in the assets exceeding limits.

In its written presentation, the respondent commented:

We deduct the current month’s income from the ending balance as it is considered income and not an asset. Please note that the burial trust was not considered in the determination as it was an exempt asset; however, the funds that were used to purchase the burial trust were considered countable assets until April when the check cleared the bank. I contacted — today to inquire about the receipt of the payment for the burial trust. I was informed that they received the payment in December of 2024, but there was an issue with the file and the check did not get deposited until April of 2025. Upon consideration of the fact that the facility was in possession of the funds in December, I deducted the amount of check 1405 for $7731.17 from the balance of the checking account for January, February and March of 2025. This brought the countable assets for January down to $1533.87, February down to $4388.02 (remained over the asset limit) and March down to $6001.90 (remained over the asset limit). I then contacted — and spoke with them about payments received in the months of question. They indicated that they received a payment of $3000 (CK 1408) on 01.14.25 and the next payment they received was for $5500 (CK 1410) on 03.31.25. The payment received in January also cleared the bank in January and was reflected on the January statement. The payment received in March did not clear the bank until April and was not considered in the March eligibility determination. Upon consideration of the fact that the facility was in possession of the funds in March, I deducted $5500 from the checking account in March. This brought the countable assets in March down to $664.79.

Exhibit R-1.

At hearing, the petitioner’s son requested that I make an exception to the rules in order for his mother to qualify for MA in February of 2025. While I am entirely sympathetic to his argument, I am unable to do so. Petitioner’s son has worked diligently to address his mother’s care needs and to ensure proper payment for same. Still, the agency has not incorrectly determined her ineligibility for MA in February of 2025. As a result, there is no error to correct. Petitioner is requesting a ruling based upon fairness, but Wisconsin Administrative Law Judges do not possess equitable powers. There is no provision in the law that would provide me with the power to waive or alter the asset limit requirements. “An agency or board created by the legislature has only those powers which are expressly or impliedly conferred on it by statute. Such statutes are generally strictly construed to preclude the exercise of power which is not expressly granted.” Browne v. Milwaukee Board of School Directors, 83 Wis. 2d 316, 333, 265 N.W.2d 559 (1978) (citation omitted). Thus, as an administrative law judge, I do not have authority to make an exception or render a decision on the basis of fairness or equity.

Conclusions of Law

The agency correctly denied the petitioner’s Institutional Medicaid eligibility for the month of February 2025.

THEREFORE, it is

Ordered

That the petition is hereby dismissed.

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