Health insurance premiums are not an extraordinary uncovered medical expense as the very nature of health insurance is that it covers certain medical services, thus insurance in and of itself would never be a covered medical expense; the MassHealth regulation only allows an increase to the MMMNA for exceptional circumstances as outlined in the above regulation and such circumstances do not include high shelter costs, unless the shelter cost is related to the community spouse’s medical condition as in the case of an assisted living resident.
Category: Denial
Appeal 1505979
The MassHealth regulation only allows an increase to the MMMNA for exceptional circumstances as outlined in the regulation and such circumstances do not include shelter costs, unless the shelter cost is related to the community spouse’s medical condition as in the case of an assisted living resident; the community spouse is 58 years old and there is no evidence of a medical condition that results in high out of pocket medical expenses; community spouse does not have extraordinary uncovered medical expenses arising from her medical condition that result in significant financial duress.
Appeal 1502486
Disqualifying transfer; appellant was the income beneficiary of a Trust that terminated in the same month she was admitted to the nursing facility; termination of the Trust was an action that was “taken to avoid receiving a resource to which the nursing facility resident or spouse is or would be entitled if such action had not been taken.”
Appeal 1404097
The HR Realty Trust is in fact revocable by appellant because she is the Settlor, regardless of her resignation as Trustee; appellant and her late husband removed the property from the HR Trust on May 20, 2004, and deeded the property back to themselves as tenants by the entirety so that they could obtain a mortgage; home is countable asset.
Appeal 1409043
Appellant-wife submitted no evidence to substantiate her claim that she has unusual medical expenses constituting the “exceptional circumstances” that would justify an increase in the SMND when calculating the appellant-husband’s PPA.
Appeal 1406406
Transfers were for less than fair market value; appellant’s brother did not possess a present life estate interest in the trust; the amount transferred to him upon the sale of the property was a disqualifying transfer.
Appeal 1401492
Fair Hearing Rehearing Decision 1401492
Rehearing: MassHealth was correct in determining that the appellant’s assets exceed the limit for MassHealth Standard long term care benefits; MassHealth was correct in its determination there was an impermissible transfer of assets.
Appeal 1215370
Husband’s purchase of an annuity resulted in a transfer of resources for less than fair market value; the Commonwealth is not a remainder beneficiary of this annuity; the regulations plainly allow MassHealth to consider as disqualifying any actions taken by either the applicant or his or her spouse, and, as part of this, to require that annuities purchased by a community spouse comport with the provisions of 130 CMR 520.007(J)(2); the annuity here does not meet those regulatory requirements.
Appeal 1217117
MassHealth determined that appellant’s income flow from the 10-year fixed period annuity is less than it should be based on her life expectancy of 7.59 years; because the current monthly annuity payments do not satisfy 130 CMR 520.007(J)(1) there is a disqualifying transfer of assets; over appellant’s life expectancy she has been and will continue to receive a total of $2051.12 less than the value of the premium paid; $2051.12 represents a disqualifying transfer.
Appeal 1209222
Nursing facility has valid grounds to discharge the appellant per its notice dated April 2, 2012; met its burden of providing sufficient preparation and orientation to the resident to ensure safe and orderly discharge; nursing facility actively involved the appellant in selecting the discharge location when the representatives met with the appellant and discussed possible discharge locations.
MassHealth Appeals 