For the Qualified Medicare Beneficiary (QMB) program, benefits cannot begin until the month after the application is processed. In this straightforward case, the petitioner applied but did not complete verification until November 14. ALJ John Tedesco concluded her benefits could not begin until December 1.
Compare, however, MQB 207807, in which ALJ Peter McCombs ordered QMB benefits backdated because the delay in verification was not the petitioner’s fault.
Preliminary Recitals
Pursuant to a petition filed on January 20, 2023, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Shawano County Department of Human Services regarding Medical Assistance (MA), a hearing was held on April 19, 2023, by telephone.
The issue for determination is whether the agency erred in its determination of enrollment date for petitioner’s QMB as of 12/1/22.
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: —
Shawano County Department of Human Services
W7327 Anderson Avenue
Shawano, WI 54166-3105
ADMINISTRATIVE LAW JUDGE:
John P. Tedesco
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Oconto County.
- On 10/11/22 the agency contacted petitioner by phone to explain the QMB program and to suggest that petitioner apply.
- On 10/12/22 the agency sent a letter informing petitioner that she could apply for QMB and that she would need to send various financial verification documents related to income and assets. The letter explained that everything needed to be received by 10/21/22 in order to avoid an interruption in benefits.
- Petitioner applied for QMB but did not provide all requested and required verification to complete the application until 11/14/22.
- Petitioner was enrolled in the QMB program as of December 1, 2022.
- Petitioner appealed seeking backdated enrollment to November 1, 2022.
Discussion
Section 301 of the Medicare Catastrophic Coverage Act (MCCA) of 1988 established an eligibility category known as Qualified Medicare Beneficiary (QMB). A Qualified Medicare Beneficiary (QMB) is an individual with income below the poverty level whose Medicare premium benefits and coinsurance and deductibles are paid for by the state Medicaid (MA) program based upon the individual’s poverty status (100% of the federal poverty level).
The petitioner applied for QMB on November 14, 2022. The application was approved on that date. She is asking for the QMB benefit retroactively to November 1, 2022. However, retroactive certification is not possible for the month of, or preceding, the application:
…in the case of medicare cost-sharing with respect to a qualified medicare beneficiary defined in subsection (p)(1)…, benefits are not retroactive.
42 U.S.C. 1396d(a). See also, Medicaid Eligibility Handbook, § 32.7.1.1 (“For initial applications, QMB benefits begin on the first of the month after the month in which the individual is determined to be eligible”) (emphasis added). Petitioner was not determined eligible until she has filed all the required verification documentation. That was on November 14, 2022. Thus, the Department’s decision to certify the petitioner for QMB effective December 1, 2022 was correct.
Conclusions of Law
The Department did not err in its denial of backdated eligibility for the QMB program.
THEREFORE, it is
Ordered
That this appeal is dismissed.
[Request for a rehearing and appeal to court instructions omitted.]