When & How to Appeal a Medicaid Denial for Long Term Care

 

Introduction
After a Medicaid denial, it’s important to file an official appeal at the right time. Denied applicants should take a few steps before appealing, but there’s also a deadline to file, and waiting too long can mean more out-of-pocket healthcare expenses. If the appeal does eventually lead to a “fair hearing,” the hearing could be convoluted and contentious. At Eldercare Resource Planning, we handle every aspect of the appeal and hearing process for our clients.

 

When to Appeal a Medicaid Denial

Some Medicaid applicants might be tempted to file an appeal immediately after receiving their denial letter, but this would be rash. Before filing an official appeal, they first need to determine if anything can be done to easily fix the problem that caused the denial. If it can be easily fixed, there’s a chance the state will allow it and reverse the denial once the situation is resolved. To do this, the applicant or their representative would make an informal request to the caseworker or whoever is handling the case instead of submitting an official request to the state for a fair hearing.

If the applicant does not get a quick reply to their informal request, they should not wait long before taking the next step, which is filing an official request for a fair hearing with the state. At Eldercare Resource Planning, we only wait 2-3 business days between making the informal request and filing the official appeal, and there are several reasons why.

First and foremost, we’ve found that roughly 65% of our official appeals lead to the denial being reversed without a hearing. That’s because the appeal forces states to take a closer look at the application, which often leads to them recognizing the mistake, and they would rather resolve the situation informally than spend the time and money it takes to have a fair hearing.

Another reason to file for an official appeal in a timely manner is that some states and caseworkers won’t take any action until an official request for appeal is filed. There’s also a deadline to file for an appeal, which is within 30-90 days of receiving the denial letter, depending on the state. Plus, the sooner the appeal is filed the sooner the applicant will start receiving benefits and stop being responsible for paying for their own long-term care. It should also be noted that if the state happens to reply to an informal request after the official request for a fair hearing has been filed, and the state is willing to go through with an informal reversal of the denial, the official appeal can be redacted.

 Available to All: Appeals can be made by applicants who have been denied by any of the Medicaid programs relevant to seniors – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers, or regular state Medicaid for seniors, also known as Aged, Blind and Disabled (ABD) Medicaid in some states.

 

What to Expect at a Fair Hearing

Most hearings are held over the phone or via teleconference. The hearing will include a representative from the state Medicaid agency, a neutral hearing officer or administrative law judge, and the appealing applicant or their representative. Since the denial and appeal process can be complicated, most appealing applicants do hire a professional to represent them, like a Certified Medicaid Planner or an Elder Law Attorney.

In some cases and states, the reasons why the applicant has been denied will be made clear by the state. It might be plainly written in the denial letter, or the caseworker may explain things in detail on a follow-up call. In these cases, what will be argued in the hearing is known ahead of time. In other cases and states, it may not be clear why the applicant was denied. Denial letters can be vague, information can be omitted, or caseworkers may not reply to any communication other than to set a date for the hearing. When this happens, what will be argued at the hearing will be unknown and the applicant or their representative needs to be well-prepared and ready for any argument the state might make.

The applicant or their representative should be prepared to provide evidence during the hearing to support their argument. This might include financial documents (bank statements, business records, tax returns, etc.), home deeds, vehicle titles, medical records, physician’s statements and communications between the applicant and the caseworker or anyone else at the state Medicaid agency (emails, voicemails or anything else documented). Both sides are also allowed to bring witnesses, and cross examine opposing witnesses.

The hearings are generally finished within a few hours, but it can take much longer for the hearing officer or administrative law judge to make their decision, which will be mailed to the applicant. This judge must be impartial. They can not be directly involved in any way with the decision being appealed.

 Time Elapsed: The entire process, from filing the official appeal to receiving a decision, should be finished within 90 days. In cases where the applicant has a serious medical need, the time-frame can be shortened.

 

If a Denial is Reversed

When the hearing officer rules in favor of the applicant and the appeal is upheld, the applicant will be approved for Medicaid. Not only will Medicaid cover their healthcare moving forward, it will retroactively cover their healthcare expenses effective from the date they would have been enrolled in Medicaid if the original application was accepted. Appealing applicants should keep all of their medical bills and receipts from the appeal time period so they can receive the full amount of this retroactive coverage.

 

Why Medicaid Applications are Denied


Medicaid applications are denied for many reasons. The following are some of the most common:

• Applicant is over their asset limit for eligibility
• Applicant is over their income limit for eligibility
• Applicant does not meet the medical criteria for eligibility
• The application contains mistakes
• The application is incomplete
• Required documents are missing
• Required documents were not provided before the deadline
• Applicant inappropriately transferred assets during the Look-Back Period
• Applicant misused a qualifying financial tool, like a Medicaid Asset Protection Trust, a Medicaid Compliant Annuity or a Qualified Income Trust
• Applicant misused a Medicaid qualifying rule, such as the Child Caregiver Exemption or the Sibling Exemption
• Applicant does not meet the citizenship criteria for eligibility

Medicaid’s eligibility criteria, rules and qualification process are all complicated. It’s easy to make a mistake in any of those areas that could lead to an application being denied, especially for a non-professional. That’s why seniors are their families are encouraged to consult with a professional before submitting their application.

 

Denial Letters

Medicaid applicants who have been denied will receive a denial letter that will state the reason(s) the application was denied, and it will likely cite the state policies that are relevant to the denial. As mentioned above, these reasons are clearly explained in some cases and states, and other times the reasons are not explained well or even at all.

The denial letter will also inform the applicant they have the right to appeal the denial with a fair hearing. It will explain how to file the appeal and when the deadline is to file it. The letter should also inform the applicant that they can represent themselves at the hearing or they can hire someone to represent them, like a Certified Medicaid Planner or Elder Law Attorney.

 

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