Medicaid Eligibility

Full-time student meets 80-hour “qualifying activities” requirement for Pathways Medicaid program

Judge Walker

February 15, 2024

A student had her application for the Medicaid Pathways program denied for failing to have 80 hours of “qualifying activities” a month.  The student appealed, arguing that the rigor and... Read More

Disabilities and caretaking responsibilities are not sufficient “qualifying activities” for Georgia Pathways

Judge Schroer

November 29, 2023

An applicant for Medicaid benefits was found ineligible for the new Georgia Pathways waiver program because she did not meet the “qualifying activities” requirement, for which she must be employed,... Read More

Judge finds support agencies unwilling, not unable, to provide services to NOW/COMP participant

Judge Fry

November 16, 2023

The Department of Behavioral Health and Developmental Disabilities (DBHDD) terminated an individual’s disability services with the New Options Waiver/Comprehensive Supports Program (NOW/COMP) after all six of the regional support coordination... 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

Veterans’ benefits were correctly counted as income for Adult Medicaid eligibility

Judge Boggs

September 7, 2023

A veteran appealed the denial of his Medicaid application, contending that the agency incorrectly included his veterans’ benefits in the calculation of his monthly income.  The Court affirmed the denial,... Read More

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

Judge Langston

September 5, 2023

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