Jessica needed medical treatment. Every time she called the Texas Health and Human Services Department (HHSC), she got the “run-around,” she said. The doctor said her Medicaid plan was inactive. HHSC said it was active.
Jessica’s Medicaid plan is called QMB (Qualified Medicare Beneficiary). For people on Disability, QMB covers expensive co-pays for treatments like the one Jessica needed. Since she couldn’t afford the co-pay for her infusions, she wasn’t getting her infusions.
It was a communication problem. The state of Texas runs the Medicaid program. But, the Social Security Disability Insurance (SSDI) and Medicare programs are run by the federal government. The state of Texas approved Jessica’s application for QMB Medicaid five years ago, in 2019. Once the state approved her for QMB Medicaid, the state was supposed to begin submitting payments to the federal Social Security Office. But the state never sent a payment. Since the people at the Social Security Medicare offices never received payments from Texas HHSC, Jessica wasn’t receiving her Medicare QMB coverage. Therefore, she couldn’t get her medical treatment.
Gloretta Thornton is a managing paralegal with LSLA. She’s been working on cases like this for almost 50 years; she started at LSLA in 1976. “We need a call to Medicare,” she said. Does Medicare know the state is paying Jessica’s Medicare Part B premium? “If not, we should file an appeal for Jessica with HHSC”
“I believe this client’s needs are urgent,” she wrote in her notes. Ms. Thornton didn’t waste time with the mail. Instead, she drove to Jessica’s house to get her signature on a few forms: Form H1826: Case Information Release, Form CMS1696: Appointment of Representative, a Hearing Request form (a form created by Ms. Thornton’s team for situations like this), and some other legal forms.
The very next day, Ms. Thornton filed an appeal.
Anyone can request a fair hearing. (When you file an appeal, you are requesting a fair hearing.) Suppose you get a notice in the mail. Suppose the notice says your Medicaid benefits are discontinued. You can:
HHSC is required to process your appeal within five days. Processing means they send it to the Appeals Office. Once your request reaches the Appeals Office, the Appeals staff can set a date for your hearing. Jessica’s appeal never made it to the Appeals Office. Therefore, no one scheduled a hearing.
A few days after Ms. Thornton requested an appeal on Jessica’s behalf, Jessica received a call from HHSC. They told Jessica she couldn’t file an appeal. Then, they told her they wouldn’t process her appeal. They said they’d fix the problem instead. Jessica was confused. The doctor’s office still said she was “inactive.”
“Have them call me directly,” Ms. Thornton advised. Jessica had given Ms. Thornton permission to speak on her behalf. Then Ms. Thornton tried calling HHSC herself. She called several times on different days and at different times. Each time, she waited on hold for an operator. Then she got a message saying “there is no operator available at this time” and the call ended. There was no way to leave a message.
Ms. Thornton sent an email. She copied two different email addresses for the fair hearings department at HHSC.
Almost a month after Ms. Thornton requested an appeal, Jessica received two confusing letters in the mail. Neither letter said anything about an appeal or a hearing.
The first letter was from the Texas agency, HHSC. HHSC said Jessica was certified for Medicaid QMB going forward. The second notice came from the Social Security Administration (SSA), a federal agency. The second notice said the opposite: her Medicaid QMB would expire in a few days. Jessica checked her YTB account (YTB stands for “Your Texas Benefits”). Her account still said “inactive.”
It had been 25 days since Ms. Thornton filed an appeal for Jessica. HHSC was supposed to process her appeal within 5 days. Instead of processing her appeal, they were trying to fix the problem on the back end. But there were new problems.
Ms. Thornton knew she had to move quickly. Jessica was already behind on medical treatments when she first called LSLA. Since Ms. Thornton couldn’t reach anyone at HHSC, she consulted with Adrian Garcia, a former HHSC hearings officer and current senior paralegal at LSLA. They decided to call the 211 Texas/United Way Help Line. “211 states that Jessica is eligible for long-term-care services but does not mention…QMB benefits,” Ms. Thornton wrote in her notes.
Ms. Thornton tried calling someone she knew at a local HHSC office. That person was friendly. The friendly person looked up Jessica’s account: Jessica was approved for QMB a few days ago, but her coverage wouldn’t start for a month, she told Ms. Thornton. Ms. Thornton knew that was wrong. Jessica was approved five years ago, in 2019. The friendly person suggested Ms. Thornton speak to the Medicaid supervisor in her office.
The conversation with the supervisor was not as smooth. Ms. Thornton tried to explain: When HHSC tried to correct their mistake, they accidentally cancelled Jessica’s coverage instead. “The agency is already beyond the five-day processing time frame dictated in section 1221 of the Fair and Fraud Hearings Handbook,” Ms. Thornton told her.
The supervisor put her on hold. Ms. Thornton waited for “quite a long time,” she said. When the supervisor came back, she said she couldn’t discuss Jessica’s case with Ms. Thornton; she could only discuss the case with Jessica. Ms. Thornton offered to get Jessica on the line right then and there. The supervisor said no. The call ended.
Ms. Thornton had no one else to call. She’d been working on Jessica’s case for a month.
Ms. Thornton consulted with Mr. Garcia again. They came up with two more people who might be able to help process the appeal and schedule a hearing. The first was a different supervisor at HHSC. Ms. Thornton dialed the number and explained the situation. “Initially, she was not very forthcoming,” Ms. Thornton says about this new supervisor.
“If you could simply see that the appeal… is properly processed so that I could receive a hearing date, I would appreciate your efforts,” Ms. Thornton said.
Again, the HHSC supervisor said they would not process the appeal because they could only process appeals submitted directly by Jessica. However, when she noticed Jessica’s signature on the form, she said she would see that the appeal was processed, but she would rather fix things if possible.
At least three HHSC workers said they didn’t want to process Jessica’s appeal. Why not? We aren’t sure, but in 2009, there was a big lawsuit called Howard and Thornberg v. Albert Hawkins. After the lawsuit, HHSC had to hire 500 more employees. Hiring 500 employees is expensive. Here is a 2009 article explaining what happened.
Since the appeal was not being processed, Ms. Thornton offered to withdraw it, but only on one condition. “If Jessica can call and make an appointment with her doctor… and the doctor can get a positive response when he checks the system for eligibility, then I won’t need a hearing,” Ms. Thornton explained.
The supervisor said Jessica’s record showed she was eligible. She said Jessica’s doctor should get a positive response.
Ms. Thornton got off the phone with the supervisor and immediately called Jessica. She asked Jessica to make an appointment with her doctor. Please ask your doctor to check on your QMB Medicaid, Ms. Thornton said. Make sure it is active.
A week later, Ms. Thornton emailed Jessica to follow up. “Were you able to get an appointment?”
A few days later, Jessica responded to Ms. Thornton. She didn’t say anything about getting an appointment, however. She told Ms. Thornton that she received a new letter from HHSC. Jessica thought it was a hearing notice. When Jessica read it to Ms. Thornton, however, Ms. Thornton knew it was a Notice of Pre-Hearing Conference. The notice gave the name and contact information for a Hearing Officer. Ms. Thornton collected the Hearing Officer’s contact information and told Jessica she would reach out to him.
Finally, almost two months after Jessica first called LSLA for help, she told Ms. Thornton: she was able to make an appointment with her doctor for the infusion treatments. The doctor verified her QMB Medicaid coverage. The pharmacy also verified her coverage. She was able to get medication refills.
HHSC didn’t process Jessica’s appeal within 5 days like they were supposed to. It took them 41 days to process her appeal. After many phone calls from Ms. Thornton, they finally fixed the problem, and processed her appeal.
Jessica has given me permission to withdraw the appeal, Ms. Thornton wrote in her notes. “She is receiving benefits from the QMB program. SSA has informed her: the state is paying her Part B premium from 10/2019 and ongoing… Sending withdrawal to HHSC Hearing Officer today.”
Ms. Thornton’s patience and dedication paid off. “You can’t withdraw your appeal until you have proof that your problem is solved,” she explains. “They promise to fix the problem. Maybe they will try to fix the problem. But I never withdraw my appeal until I can see the problem is fixed and the client is getting the services they need.”
*Names have been changed to protect the identity of the client(s).
Lone Star Legal Aid (LSLA) is a 501(c)(3) nonprofit law firm focused on advocacy for low-income populations by providing free legal education, advice, and representation. LSLA serves millions of people at 125% of federal poverty guidelines, who live in 72 counties in the eastern and Gulf Coast regions of Texas, and 4 counties in Southwest Arkansas. To learn more about Lone Star Legal Aid, visit our website at www.LoneStarLegal.org.
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