Medicaid Eligibility

Given physical risks involved, GAPP recipient still required nursing services during therapies

Judge Woodard

January 9, 2023

In this matter, a 3-year-old recipient of nursing services through the Georgia Pediatric Program (GAPP) appealed a decision by the Department of Community Health to reduce his service hours from... Read More

Series of low IQ scores demonstrated applicant’s eligibility for NOW/COMP

Judge Schroer

January 4, 2023

The Court concluded that an applicant met the eligibility criteria for the NOW/COMP Medicaid waiver program based on his history of low IQ scores.  The evidence showed the applicant demonstrated... Read More

Adjustment to Nursing Home Medicaid resource allowance does not require showing of undue hardship

Judge Schroer

December 14, 2022

This matter involved the denial of a Medicaid application on the grounds that the applicant—who lives in a nursing facility—and her spouse had combined assets that exceeded the “community spouse... Read More

NOW/COMP applicant failed to show sufficient deficits in intellectual, adaptive functioning   

Judge Woodard

September 27, 2022

In this matter, a 20-year-old woman seeking benefits under the New Options Waiver/Comprehensive Supports Program (NOW/COMP) had her application denied.  In upholding the denial, the Court concluded the applicant failed... Read More

Medicaid properly denied, as evidence was not sufficient to show blindness or disability

Judge Kennedy

September 26, 2022

A woman suffering from partial blindness applied for Medicaid benefits under the Aged, Blind, and Disabled category.  The state’s Division of Family and Children Services (DFCS) denied the application, and... Read More

Denial of Medicaid services upheld based on patient’s untimely request for therapy services  

Judge Walker-Russell

August 9, 2022

The Court upheld the decision to deny a patient’s request for physical therapy services under the Georgia Families Medicaid Program.  The patient had made her request approximately 151 days from... Read More

Test results provided by applicant insufficient to reverse denial of NOW/COMP application

Judge Woodard

March 1, 2022

In upholding DBHDD’s denial of an application for NOW/COMP benefits, the Court concluded there was insufficient evidence the applicant had significantly impaired adaptive functioning in at least three areas.  Although... Read More

GAPP recipient given insufficient notice as to why benefits were reduced

Judge Walker

February 28, 2022

This case involved an appeal of the Department of Community Health’s decision to reduce services provided to a child through the Georgia Pediatric Program (GAPP).  In remanding the case to... Read More

Standing of Facility in Medicaid Appeal

Judge Howells

April 28, 2021

The Court rejected the Facility\'s argument that it had standing or authority to appeal the denial of a resident\'s Medicaid application and found that the hearing request was untimely. Read More

Agency did not follow proper procedures in terminating member’s NOW/COMP services  

Judge Walker-Russell

June 3, 2020

This case involved the termination of a patient’s Medicaid benefits under the New Options Waiver and Comprehensive Supports Waiver Program (“NOW/COMP”).  The Court concluded the agency had improperly terminated the... Read More

Staged procedures may be covered by Medicaid where shown to be medically necessary.

Judge Malihi

August 25, 2017

DCH erred by denying prior Medicaid authorization for a bilateral nipple/areola reconstruction and nipple tattooing procedure incident to bilateral breast reduction surgery, the fact that both procedures were not performed... Read More

The agency failed to support its position that blindness/hearing loss were not functional impairments.

Judge Malihi

June 8, 2017

The Department of Community Health failed to support its argument that a SOURCE beneficiary could not show that she met the level of care requirements through evidence of blindness and... Read More

Where a valid court order of support exists, Respondent must increase a nursing home community spouse’s monthly income allowance by the amount of the ordered support.

Judge Schroer

March 13, 2017

When determining the amount a nursing home resident must pay each month toward the costs of care in a nursing facility, if the resident has a community spouse and a... Read More

Hospice services sufficient evidence that child met institutional level of care criteria

Judge Woodard

February 8, 2017

Evidence that a child born with a terminal condition received hospice services from a skilled professional at home during the one month he was alive was sufficient to show that... Read More

Transfer penalty inappropriate because real property was sold for current market value.

Judge Malihi

January 10, 2017

A nursing home resident proved that his property was worth significantly less than was alleged by the Division of Family and Children Services by submitting the affidavit of a realtor... Read More

Receipt of Emergency Medicaid requires proof of Georgia residency.

Judge Baxter

June 8, 2016

A citizen of Belize who was flown into Georgia to receive treatment after a butane tank explosion in Belize was not entitled to Emergency Medicaid because he did not establish... Read More

DFCS must make eligibility determination when SSA’s 90-day period elapses.

Judge Miller

October 26, 2015

When a Medicaid applicant applies for Supplemental Security Income through the Social Security Administration (SSA), DFCS generally does not make an independent determination of blindness or disability. Instead, SSA makes... Read More

Deviation from financial eligibility formula set forth in Medicaid Manual improper.

Judge Schroer

June 29, 2015

Petitioner was properly denied Medicaid under the “Qualified Medicare Beneficiary” class of assistance, as her total net income exceeded the income limit for that Medicaid category.  Petitioner is eligible for,... Read More

DFCS cannot toll the transfer of assets penalty period.

Judge Woodard

June 29, 2015

The Department of Human Services’ Division of Family and Children Services (“DFCS”) assessed a penalty of 3.43 months against Petitioner for transferring $20,020.46 of her assets without receiving fair market... Read More

Transfer of resources penalty improper due to probate court order.

Judge Woodard

March 21, 2014

The Division of Family and Children Services’ (DFCS) was not authorized to impose a transfer-of-resources penalty, because the probate court had already determined that the Medicaid applicant’s conservators had made... Read More