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  • Writer's pictureKathy L. McNair, Esq.

What to expect when you apply for Medicaid for Nursing Home Care- 9 Tips

If you or a loved one need nursing home care, Medicaid (in Massachusetts it is also called MassHealth) can help pay for your care. However, the application process can be grueling. Here are nine tips to make the process go smoother:

1. Hire an elder law attorney. Most people need to spend down money before they will qualify for MassHealth benefits. An elder law attorney can help you figure out where to start. In most cases, we are able to make recommendations with options that are much better than just spending the excess money paying for the nursing home. We can also prepare the Medicaid application and walk you through an extremely complicated process. The legal fee is an allowable expense before you apply for Medicaid. If you wait until you apply and then need help, it will no longer be an allowable spend down expense. The costliest mistake is not hiring an elder law attorney as soon as possible.

2. Do not apply for Medicaid until you have reduced your assets below the limit:

A single person is only allowed to have $2,000 or less. in 2022, a married couple, when one spouse needs nursing home care, is allowed to have roughly $139,000. Even if your assets are over this amount, an elder law attorney can guide you in protecting assets. You should not submit an application until you are sure that your asset are below the limit. If you submit the application too soon, you will only be allowed to reduce your assets paying for medical expenses, when you may have had better options. Note: If your spouse needs nursing home care, his or her assets must be reduced below $2,000 within 90 days of the approval.

3. Apply within 90 days of the date you reduced your assets. Coverage will be retroactive to the first day that you met the financial eligibility and clinical requirements, as long as you apply within 90 days of the first day that you need coverage. If you are running out of time, submit your signed application without any further documents. You can provide these later.

3. Be prepared for a financial strip search. If you want to receive MassHealth benefits, you will have to subject yourself to invasive scrutiny of your finances and will need to provide financial statements, health insurance information, real estate deeds, and other documents for up to the past five years.

4. Expect a "Request for Information". After you submit your application, you should receive a letter within a few weeks from the caseworker assigned to your case, titled "Request for Information", listing the additional information that you will need to provide. You usually have about 3-4 weeks to provide the information. If you need more time, you can usually get it, but you will likely need to appeal.

5. Stay organized. For our cases, we prepare a table of contents with an application, with numbered sections, and corresponding tabs. It is important to keep a copy of everything you submit, because you may need to submit it again, or may need it for an appeal, etc.

6. Expect at least one denial. Almost every case will receive at least one denial, if not more. Hopefully, you have hired an elder law attorney to help you navigate this. If not, be sure to fill out the fair hearing request form as soon as you receive the denial. You only have a short window of time to file this. This is important even if you think you can resolve it without a hearing. You can always withdraw the hearing if your case is approved.

7. Be patient and expect the process to take six months or more. Even if you follow all of the tips above, the application takes months to get approved. In the best case, it will take a few months, but some cases can take over one year, some involving multiple hearings along the way.

8. Keep the nursing home informed of the application status. Nursing homes would rather have a professional helping you since the process is so complicated and if it gets denied they risk losing a lot of money. If you are doing it yourself, be sure to keep the nursing home updated on the status.

9. Pay the estimated monthly Patient Paid Amount (PPA) to the nursing home. The Medicaid applicant is required to pay an estimated patient paid amount (PPA) to the nursing home each month beginning in the month you want the coverage to start, even while the application is pending. This amount is complicated to calculate and based on your unique situation. It depends upon your income, spouse's income, health insurance and expenses. It can range from as high as the nursing home applicant's monthly income (less $72.80 for his/her personal needs) to as low at $0. If you haven't hired an attorney to help you, you should ask the business office at the nursing home if they can provide guidance.

Applying for MassHealth is stressful, at a time when you may already feel overwhelmed with grief. I don't recommend that you do it yourself, especially if your assets are (or were) over the limit before applying. Over the past twenty years, we have filed hundreds of Medicaid applications. It is best to take it one step at a time and to remain calm.

If you or a family member needs nursing home care, 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:

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.

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