QMB benefits cannot normally be backdated (compare MQB 207494), but an ALJ can order backdating following a fair hearing. In this case, the Social Security Administration conceded that its own error caused a 3-month delay in verification and enrollment. ALJ Peter McCombs ordered the petitioner’s QMB backdated, as the delay was not the petitioner’s fault.
QMB can be backdated if the eligibility process was not completed within 30 days, the certification process was not completed, or by a fair hearing order. MA Handbook, §32.8.1.
Preliminary Recitals
Pursuant to a petition filed on February 27, 2023, under Wis. Stat. § 49.45(5), and Wis. Admin. Code § HA 3.03(1), to review a decision by the Marathon County Department of Social Services regarding Medical Assistance (MA), a hearing was held on June 1, 2023, by telephone.
The issue for determination is whether the respondent correctly denied petitioner’s request to commence her QMB eligibility effective November 1, 2022.
There appeared at that time the following persons:
PARTIES IN INTEREST:
Petitioner:
—
Petitioner’s Representative:
Attorney Christine J. Huberty
GWAAR — Elder Law & Advocacy Center
1414 MacArthur Rd Suite 306
Madison, WI 53714
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Gao Shou Lor
Marathon County Department of Social Services
400 E. Thomas Street
Wausau, WI 54403
ADMINISTRATIVE LAW JUDGE:
Peter McCombs
Division of Hearings and Appeals
Findings of Fact
- Petitioner (CARES # —) is a resident of Marathon County.
- Petitioner applied for medical assistance, FoodShare and Qualified Medicare Beneficiary (QMB) Program enrollment on September 28, 2022.
- Although a Medicare Savings Benefit request was entered by the agency upon her application, it was not tested because petitioner was not entitled to Medicare Part A or B at that time.
- On October 2, 2022, petitioner requested a receipt from the Social Security Administration (SSA) office regarding her Medicare Part A eligibility.
- On January 12, 2023, the agency received a phone call from the SSA office regarding the Medicare Savings Benefit request made by petitioner in September of 2022. The caller from Social Security informed the agency that petitioner became entitled to Medicare Part B as of October 1, 2022.
- Since the petitioner did not have Medicare Part A, the agency called the Social Security worker back on January 18, 2023 to request that they assist petitioner in applying for Part A and to submit the receipt to show the Part A begin date to allow the agency to test her Medicare Savings Benefit eligibility.
- The agency also sent a verification check list to the petitioner on January 12, 2023 requesting the receipt identifying her Part A entitlement date.
- The agency received a letter from SSA on January 24, 2023. The agency accepted this as receipt of Part A enrollment and approved QMB as of February 1, 2023.
- The Medicaid Eligibility Handbook provides that, for initial eligibility, QMB benefits begin on the first of the month after the month in which the person is determined to be eligible, and the case is confirmed in CARES.
- SSA failed to properly provide petitioner with her receipt in October of 2022, and conceded that its error led to the issue on appeal.
Discussion
Petitioner filed this appeal because the agency denied her request to commence her QMB eligibility as of November 1, 2022. QMB, SLMB, and SLMB Plus are programs that provide assistance with Medicare premiums for persons whose incomes are over the regular Medical Assistance limits. See Wis. Stat., §49.468. All three programs pay the entire Part B premium, but QMB also pays for Medicare deductibles, copayments, and coinsurance. See the MA Handbook, §32.1.1 for a full description of the programs and §32.1.3 for the benefits each pays.
QMB can begin on the first of the month after the month the person is determined to be eligible. MA Handbook, §32.7.1.1. The SSA conceded that it erred in processing petitioner’s information, and this resulted in the respondent’s erroneous commencement of petitioner’s QMB enrollment in February of 2023. The agency based its determination of petitioner’s enrollment date on the SSA’s belated submission of her Medicare Part A enrollment receipt in January of 2023. The agency concluded that, based upon the SSA submission, petitioner was eligible for QMB in January, 2023, making her eligible the first of the next month.
The situation here is unusual, however there are few facts in dispute. Petitioner applied for benefits in September of 2022, and while it is true that initially her Medicare eligibility did not show, she did become eligible effective October 1, 2022. The agency should have received receipt of that eligibility determination in October of 2022, which would have allowed for QMB enrollment as of November 1, 2023.
QMB can be backdated if the eligibility process was not completed within 30 days, the certification process was not completed, or by a fair hearing order. MA Handbook, §32.8.1. I thus can order backdating here. I will order that petitioner’s QMB enrollment commence effective November 1, 2022, as the delay in commencing her enrollment was caused by the SSA office, and was not due to any error or omission on the part of petitioner.
Conclusions of Law
Petitioner’s QMB should be backdated to November 1, 2019 because the delay in her QMB enrollment was caused by the SSA office, and was not due to any error or omission on the part of petitioner.
THEREFORE, it is
Ordered
That the matter be remanded to the agency with instructions to grant QMB eligibility for the months of November, 2022 – January 2023. The agency shall do so within 10 days following issuance of this decision.
[Request for a rehearing and appeal to court instructions omitted.]