Introduction
By the time most seniors apply for Medicaid, they are in need of long-term care, but that care isn’t available as soon as they turn in their application. They have to wait for a response from the state, which can take months. This can be a challenging time for some seniors, but they may be able to find the care they need thanks to Medicaid Pending.
Seniors who have applied for Medicaid but have not received a reply from the state have Medicaid Pending status. Some nursing homes and care providers in the community will accept Medicaid Pending residents and clients. They do this knowing the Medicaid Pending senior may not be able to pay all, or perhaps any, of their bill, but assuming they will be reimbursed by Medicaid once the application has been approved. However, nursing homes and caregivers are not required to accept Medicaid Pending residents or clients. It is their choice.
A senior’s Medicaid Pending status lasts until the application has been approved or denied, and that includes time to request and have a fair hearing to appeal a denial. In theory, states are required to respond to Medicaid applications in 45 days, or 90 if a disability determination is needed, but the reality is it can take longer and usually does. If the application is denied, requesting and having a fair hearing to appeal the denial could then take more weeks or months depending on how long it takes to file the appeal and how many other appeals the state is handling at the time. So, it’s possible for a senior to have Medicaid Pending status for as long as six or seven months.
The first step is finding a suitable nursing home in the right area that accepts Medicaid Pending, which can be difficult. Nursing Home Compare, a search tool administered by the Centers for Medicare & Medicaid Services, is a good place to start, but it doesn’t have a filter that allows one to search for homes that accept Medicaid Pending. The only way to find out that information is by calling the nursing home and asking if they accept Medicaid Pending and if there are spaces available. Seniors should be prepared to share copies of their Medicaid application and all of its verifying financial documents with nursing home administrators. They will want to see for themselves how likely it is for the senior to be approved.
Once accepted into a nursing home, Medicaid Pending seniors can not be evicted as long as they have their Medicaid Pending status. Nursing homes must allow these residents to stay as long as their application is pending, and if there is a denial they must also allow them to stay long enough to have a fair hearing to appeal the denial. If there is a final denial, the nursing home can evict the resident if they can not pay their bills. However, the facility must provide a full health assessment and a care and residence plan for the denied applicant before evicting them.
Some nursing home administrators may ask families to pay the nursing home bills while their relative has Medicaid Pending status, but families should not do this. Making these payments could actually make their loved one ineligible for Medicaid. Plus, the beneficiary’s family is not responsible for the bills, with the possible exception of a surviving spouse. And chances are Medicaid will not reimburse the family for their payments, even if the applicant is approved.
The Medicaid programs that cover long-term care in the community are Home and Community Based Services (HCBS) Waivers and Aged, Blind and Disabled (ABD) Medicaid. This includes seniors living in their own home or the home of a loved one, and in other locations depending on the state and program, including assisted living facilities, adult foster homes and memory care units for Alzheimer’s disease and other dementias. Applicants to these programs who are waiting for a response from the state, or appealing a denial, have Medicaid Pending status. To use that status and receive long-term care without paying, they need to find a caregiver or agency willing to provide Medicaid Pending services, which can be a challenge. The experience of a Certified Medicaid Planner can be helpful in these situations, and there are resources like Area Agencies on Aging that can help seniors locate care providers who accept Medicaid Pending patients.
As with nursing homes, seniors should be prepared to share copies of their Medicaid applications and financial documents with care providers who are considering accepting them. Also, families should not pay caregivers while the applicant is Medicaid Pending because it could jeopardize their eligibility and the payments are not likely to be reimbursed.
While this process is similar to Medicaid Pending in nursing homes, there is one significant difference. Medicaid Pending seniors in the community should not expect caregivers or agencies to provide care for the duration of their Medicaid Pending status. Some caregivers and agencies may do this as a policy, or because of state mandate or funding stipulations, but they are not required to like nursing homes. Seniors should ask about this during their initial contact with potential care providers so they know what to expect.
When an application has been approved, Medicaid will reimburse the nursing home or community caregiver for the long-term care they provided the Medicaid Pending senior dating back to their application date, as long as that care would have been covered by their Medicaid plan. This includes room and board payments for Nursing Home Medicaid beneficiaries, but it will not include room and board for HCBS Waivers or ABD Medicaid beneficiaries who are in assisted living facilities. Medicaid will then continue to cover the nursing home or care provider costs.
When an application has been denied, the applicant has a right to request a fair hearing to appeal the denial. This process can be complicated and contentious, and we recommend consulting with a professional like a Certified Medicaid Planner or Elder Law Attorney before attempting an appeal. If the appeal is successful, the applicant will be enrolled in the program they applied for and Medicaid will reimburse all relevant long-term care bills the senior accrued while they had Medicaid Pending status dating back to their application date.
If the appeal is not successful, or the denial is not appealed at all, the applicant will lose their Medicaid Pending status. Nursing homes can evict seniors at this point if they can’t pay their bills, but the home must provide a health assessment and relocation and care plan before evicting. Community caregivers are likely to stop providing care without payments. The senior will be responsible for all expenses accrued, although they will not be able to pay in many cases. Both nursing homes and caregivers will attempt to collect payment from the senior and, potentially, their family. However, families are not responsible for these bills, as mentioned above, with the possible exception of a spouse.
All states have Medicaid Pending status, and it works the same in every state. However, there are many state variations that can affect Medicaid Pending seniors and the Medicaid Pending process. Application approval time can vary by state, as can the process to request a fair hearing to appeal a denial. Eligibility criteria also varies by state, so a senior might be approved for Medicaid in one state but denied in another. Some states may have more nursing homes that accept Medicaid Pending residents, some states may have fewer.
Both programs will reimburse care providers for services delivered while seniors were not enrolled in Medicaid. The essential difference is Retroactive Medicaid can pay for care prior to the application date while Medicaid Pending can pay for care after the application date. This is provided the applicant was found to be Medicaid-eligible for that whole time period.
Retroactive Medicaid will cover nursing home care for up to three months prior to the application date. This is especially helpful when a senior has a sudden need for nursing home care and has not started the Medicaid application process. Unlike Medicaid Pending, Retroactive Medicaid does not apply to HCBS Waivers or ABD Medicaid applicants.
Our team of Certified Medicaid Planners™ will help you navigate the difficult landscape of Medicaid for long-term care.
