Blog Series Part 7: Medicaid Application Denials

The complex nature of the Medicaid application process can lead to more “denials” than one would expect.  The obvious assumption is that most applications are denied because the applicant is financially ineligible or improperly gifted assets.  However, there are a number of other reasons why an application may be denied.  This post will discuss some of the potential (and easily avoidable) causes of denial and what to do if it happens to you.

Missing Information – One of the most common reasons for the flat-out denial of a Medicaid application is the applicant simply failing to send in the supplementary documentation requested by the assigned caseworker.  Over my years working as a nursing home administrator and then later in my elder law practice, I saw countless deserving, otherwise eligible Medicaid applicants receive denial notices because they failed to respond in a timely fashion to requests for copies of additional documentation.  The easiest way to ensure your application is properly processed by your local Department of Public Welfare County Assistance Office (“CAO”) office is simply to give them WHAT they ask for, WHEN they want it.

Within a few weeks of submitting your application, the first thing you will receive is a notice assigning a caseworker to your application and letting you know the additional information that the caseworker will need to make a determination.  The notice also provides a date by which you need to submit the documents.  Do NOT disregard this date.  As the process continues, you repeatedly may be asked to submit more clarifying documentation, with a new deadline applied each time.  Keep in touch with your caseworker and if you are having trouble getting your hands on old or lost documentation, make sure they know that and ask for an extension of time.  Failing to send in exactly what is requested basically guarantees your application will be denied.

                  Ineffective Caseworker – While pointing this out won’t earn me any bonus points with the Department, the truth is that not all CAO caseworkers are created equal.  For every caseworker who knows the rules inside and out and cares deeply about her job, there is another case worker who is just learning the rules and is completely overwhelmed by her caseload.  Unlike the customer, the caseworker is NOT always right.  If you find that your application is being unexpectedly denied and you don’t agree with the caseworker’s interpretation of the law or the facts, politely point them in the right direction.  Argue your side, ask for contact information for the supervisor and get her or him involved.  Work your way up the chain.  Elder law attorneys do this exact thing for their clients all the time and often have the direct emails and phone numbers for every supervisor at the DPW offices in their region.  Do not simply accept “No” for an answer if you feel a mistake has been made.

Lying To Your Caseworker – This will be a short one – simply don’t do it.  Don’t try to hide assets or hide transfers.  If you made a transfer within the past 5 years, before you even submit the application you should be prepared to disclose it and have a plan for handling it, including setting forth the applicable calculation of any ineligibility period. Try to make it as easy as possible for the caseworker – don’t treat it as an adversarial relationship.

The Appeals Process – When a final determination of ineligibility has been issued, the applicant has 30 days from that date to request a fair hearing to appeal the decision.  An appeal form is typically provided on the reverse side of the determination notice.  The CAO first must offer the appellant an opportunity to have an informal conference in the hopes you can resolve the issue prior to the hearing.  ALWAYS take advantage of this excellent opportunity for informal communication, if only because it gives you more information on the agency’s arguments prior to the hearing.

Should your case not be resolved prior to the hearing, you or a representative will have the opportunity to present evidence and call witnesses at the hearing arguing your case, including cross-examining the CAO’s witnesses.  Final determinations are made by Hearing Officers who are DPW officials.  Their role is to conduct the hearing in an orderly, but informal manner, obtain relevant testimony and render a decision based on facts and evidence as applied to the State’s regulations.  Federal regulations require the Department to issue a Final Administrative Action Order within 90 days of that hearing. If the final order remains unfavorable to the applicant, there is still one more chance to apply for further reconsideration by the Secretary of DPW.

The bottom line is that even if you have made some of the mistakes listed earlier in the article, the appeals process offers several opportunities, both formal and informal, to correct the situation.  One must remember that there are always opportunities to settle if you remain open to discussing your case and continue attempting to resolve the issues under appeal.

This blog post was originally created by Joellen Meckley while she served in an “Of Counsel” position in our firm. While she no longer does that, we do maintain a  professional relationship and if you have any Elder Law needs, I’d recommend you reach out to her firm Meckley Law. If you need Estate Planning, please reach out to us.



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