Medicaid Eligibility

DBHDD properly utilized standard methodology in determining reduction of skilled nursing hours

Judge Langston

September 14, 2023

In upholding the reduction of a NOWCOMP recipient’s skilled nursing service hours, the Court concluded that the Department of Behavioral and Developmental Disabilities (DBHDD) abided by its standardized methodology for... Read More

Patient hardship not sufficient cause to reduce Medicaid cost share

Judge Beaudrot

September 11, 2023

A nursing home resident, through her healthcare advocate, requested that her Medicaid patient liability be decreased given her inability to otherwise maintain a reasonable quality of life. The Court denied... Read More

Validity of debt thrown into question in Medicaid transfer-of-assets case

Judge Teate

August 25, 2023

The central question of this case was whether a $60,000 transfer that a Nursing Home Medicaid recipient allegedly made to her daughter as payment toward a debt was exempt from... Read More

Sale of non-homeplace real property is not excluded from calculation of transfer-of-assets penalty

Judge Teate

August 4, 2023

In this case, the Court affirmed the transfer-of-assets penalty assessed against a Medicaid recipient following the sale of his non-homeplace real property at a rate below market value. The Court... Read More

CCSP applicant should not be penalized when agency worker misplaces medical records

Judge Schroer

July 6, 2023

The OSAH Judge reversed the Department of Community Health’s denial of a Community Care Services Program (CCSP) application because it was “incomplete.”  The applicant’s daughter had provided a binder of... Read More

Court rules that developmental disabilities do not preclude physical impairment when evaluating eligibility for EDWP services

Judge Schroer

June 30, 2023

The Department of Community Health (DCH) denied an application for Medicaid’s Elderly and Disabled Waiver Program (EDWP) because the 30-year-old applicant’s primary diagnosis was cerebral palsy, which is categorized as... Read More

Diagnoses of ADHD and schizophrenia do not qualify as “closely related conditions” under NOW/COMP

Judge Walker-Russell

June 12, 2023

The Court denied an applicant’s request for benefits under Medicaid’s New Options Waiver/Comprehensive Supports Waiver Program (NOW/COMP) because he did not meet the criteria of having an intellectual disability or... Read More

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

Reduction in NOW/COMP hours was justified by change in medication administrations

Judge Fry

November 22, 2022

This case involved an appeal by a patient receiving nursing services from Medicaid’s New Options Waiver/Comprehensive Supports Waiver Program (NOW/COMP).  The Department of Community Health contended that it reduced the... Read More

Medicaid applicant found eligible for SLMB, but not eligible for any other Q Track benefits

Judge Boggs

November 3, 2022

An applicant for Medicaid benefits was found eligible for benefits under the Specified Low-Income Beneficiary class of assistance (SLMB), which is a Q Track class of assistance.  However, he appealed... 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