Medicaid is a program which provides financial assistance for skilled nursing care. There are strict eligibility criteria, and the regulations are nuanced and complex. However, a Medicaid denial does not mean you will not eventually qualify for benefits. A Medicaid denial can be appealed.
A Medicaid application may be denied for several reasons, including:
Missing documentation. You must provide providing including Social Security statements, years of bank records, property deeds, retirement accounts statements, and insurance records, among other things.
Excess assets. To qualify for Medicaid benefits a nursing home resident may have no more than $2,400 in “countable” assets (in most situations).
Transferred assets. If you transferred assets for less than market value within five years before applying for benefits, you may be subject to a penalty period before you become eligible for benefits.
The Medicaid agency is required to issue the denial notice with 45 days of the application. The notice will explain why the application was denied and how to file an appeal. The denial notice will tell how long you have to file an appeal—the deadline may be as short as 30 days or as long as 90 days after the denial notice. The application can often be corrected informally within that timeframe without a formal appeal.
Appealing a Decision
It is important to file the appeal before the deadline. The appeal should be in writing so that there is a record of it. Once your appeal is submitted, the Medicaid agency will schedule a hearing. Applicants must attend the hearing or their case will be dismissed. You have a right to have witnesses testify at the hearing and to question the Medicaid agency’s witnesses. It is a good idea to have an attorney help you through the appeal process.
If you win the appeal, your benefits will be retroactive to the date of your eligibility—usually the date of your application. If you lose the appeal, the notice will explain how to appeal the decision. The next step in the appeal process usually involves submitting written arguments. If the next appeal is unsuccessful, then you will have to appeal to court.
If your application was denied correctly due to excess assets or income, there are steps you can take to spend down your assets or put your income in a trust. Contact the Law Offices of Luschas, Naparsteck, & Crane, LLP at 570-784-4654 to find out what options you have to qualify for Medicaid benefits.