If you apply for long-term care assistance through Medicaid (also called "MassHealth") and your application is denied, the situation may seem hopeless. The good news is that you can appeal the decision.
Medicaid is a program for low-income individuals, so it has strict income and asset eligibility requirements. Qualifying for Medicaid requires navigating the complicated application process, which has many potential stumbling blocks. However, a Medicaid denial does not mean you will not eventually qualify for benefits.
The Medicaid agency may deny a Medicaid application for a number of reasons, including the following:
Missing documentation. You need to show proof that you are eligible for benefits, which usually means providing Social Security statements, bank records, property deeds, retirement accounts, and insurance records, among other things.
Excess assets. In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in "countable" assets (in most states).
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 (or 90 days if you filed for benefits on the basis of a disability). When you get a denial notice, read it carefully. The notice will explain why the application was denied and specify how to file an appeal.
Before filing a formal appeal, you can try informally asking the agency to reverse the decision. If you made a mistake on the application, this is the easiest and quickest way to proceed. If the caseworker made a mistake, it may be more complicated and require escalation to a supervisor or a formal appeal.
Appealing a Decision The denial notice will tell how long you have to file an appeal—the deadline is usually as 30 days, but it could be as short as 14. It is important to file the appeal before the deadline. Whether the denial notice requires it or not, you should submit your request for an appeal in writing, so that there is a record of it. In our office, whenever we get a denial, we almost always file an appeal immediately. If the issue gets resolved, you can always cancel the appeal hearing.
Once your appeal is submitted, the Medicaid agency will set a hearing date. Applicants must attend the hearing or their cases 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 to help you through the appeal process. An attorney can make sure you have all the correct documentation and information to present at the hearing. In our office, we have handled hundreds of Medicaid appeal hearings.
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 filing an appeal with the courts. It is crucial to have the assistance of an attorney for this.
Reapplying for Benefits If your application was denied due to excess assets or income, there may be steps you can take to resolve it. As elder law attorneys, we can advise you on correcting the situation, if possible. It may make sense to submit a new application. Note that when you reapply for benefits, your eligibility date will change to the date of the new application.
If you or a family member needs nursing home care and is applying for MassHealth, we are here to help guide you through the MassHealth application and protect your assets. Please take the next step and call our office at 617-489-5900 or schedule a brief free consultation or by clicking: https://seniorsolutions.as.me/FreeConsult
Senior Solutions, Attorneys at Law, is an Estate Planning and Elder Law firm, serving the Greater Boston, Massachusetts area, since 2001. We are ready to help you with Medicaid Planning, Estate Planning, Probate, Guardianship & Conservatorships, Special Needs Trusts, and Fiduciary Services.