QMC

What to Do When Medicaid is Denied

When a person enters long-term care in a nursing home, if they insufficient assets to pay for the full term of their long-term of their long-term care and healthcare. If so, that resident and the resident’s family members must contemplate the prospect of filing a nursing home Medicaid application. The application is made to the applicable Medicaid office, the Medicaid application is assigned to a state Medicaid caseworker to begin the application process. If all of the Medicaid eligibility criteria has been met, the application will be approved, and the resident will continue to receive the care they require, and the payment for that care will proceed smoothly.

In most cases, and at QMC in ALL cases, Medicaid applications are not filed until there is assurance that the applicant fully qualifies for Medicaid nursing home care. And that is the best route in all cases: a Medicaid application for Medicaid benefits should always meet all Medicaid requirements before it is even submitted.

But, on occasion, even the best laid plans go astray, and a family receives a Medicaid denial notice of ineligibility.

Can Medicaid eligibility still be achieved?

In almost all cases, the answer is Yes.

But, what to do next?

The first step to take is to determine the reason for the denial. There are typically only three reasons that Mediaid applications are denied:

  1. Full information was not provided to the Medicaid program. If a Medicaid application is incomplete, typically the state Medicaid caseworker will issue a Request for Information (RFI) outlining the missing information. If it is clear that the attempt to file for Medicaid coverage was an honest effort made in good faith, a refusal to enter the application into the system for processing rarely happens. The application is accepted for processing, and the RFI for the missing information is sent to the resident and resident family member. Ultimately, if that required information is not received, a denial letter will be issued.

  2. The applicant held too much in the way of assets, is over the applicable asset limit, and thus in violation of the Medicaid rules. Often the Medicaid denial is due to the fact that the Medicaid applicant is over the applicable asset limit (fyi, there are no income limits). In Missouri, the applicable asset limit for a person requiring long-term care in a Medicaid nursing facility is currently $5,800. The asset limit eligibility requirements are very strict. The assets held by the resident must be under the applicable asset limit, and not one penny over.

  3. The resident has made previous gifts within the Medicaid lookback period, thus creating a penalty period before qualifying for full enrollment in the Medicaid program. Medicaid highly restricts a prospective Medicaid coverage recipient’s ability to give away assets in order to hasten the application date and the Medicaid coverage date, instead of using those funds on care. Any improper gift made within 5 years of the Medicaid application date, will cause a penalty period before Medicaid will begin and a denial of immediate Medicaid eligibility.

  4. And a variety of other reasons.

Once the reason for the denial has been determined, what to do next? The first best step to take is to immediately retain professionals to handle the matter (like QMC). QMC has handled thousands of Medicaid applications, appeals, reinvestigations, Division of Asset filings, requests for information, etc. Or seek legal advice from an experienced elder law attorney.

But if the family insists on relying solely on self-help, here is a primer on how to handle the discouraging receipt of a Medicaid denial notice.

First, immediately contact the state Medicaid agency that issued the denial notice. The best person to attempt to contact is the state Medicaid caseworker that issued the denial notice. The goal will be to determine exactly why the Medicaid application was denied. Once that has been determined, the denial can often be reversed if the error can be reversed immediately, receiving a waiver of the Medicaid denial. For example, if the application was denied because of missing information, can that information or documentation be produced quickly. If the denial was due to excess funds, can funds be expended (perhaps to the nursing home or care provider) immediately in order to reduce countable assets under the applicable limit. Etc.

Additionally, if the family feels that the application has been rejected incorrectly, an immediate Medicaid appeal can be made, and the appeal process begun (similar to a Medicare appeal). If an appeal has been successfully filed, the matter will be decided by an administrative judge in what is known as a fair hearing.

If neither of these avenues is available, but the family has determined the source of the problem, a new Medicaid application should be immediately filed in order to avoid any more undue delay in obtaining Medicaid coverage.

In conclusion, it should be stated, it should rarely if ever come to this. Preplanning, estate planning, Medicaid planning, and the retainment of qualified professionals (like QMC) can all employed before the application date to ensure that the Medicaid application will be successful and full long-term care, medical care and health coverage continues without interruption.

Leave a Reply

Your email address will not be published. Required fields are marked *

Shopping cart close