The Imperfect Medicaid Approval – Part 2

In my post last week, I wrote about a trend we are seeing with our Medicaid applications – with every approval we get there almost always is something incorrect about the decision.  Last week I told you that some of the mistakes can be easily corrected.  Others, however, require that we file an appeal,  known as a fair hearing.

The fair hearing is the first level in the Medicaid appeal process.  The appeal is scheduled to be heard in the Office of Administrative Law (OAL) before an administrative law judge.  Strict timelines apply, however, to the right of appeal.  A notice of appeal must be submitted to the OAL within 20 days of Medicaid’s decision.

We have had to file such an appeal in a number of our cases when our requested start date for Medicaid has not be granted.  In other words, our application was approved but for a date later than what we asked for and typically there is no explanation as to why.

This happens because rarely do we file the application before our requested start date.  First of all, the mountain of documents required and the level of detail necessary causes the paperwork associated with each application to reach into the thousands of pages.  It can sometimes take clients and their families months to gather together what is necessary.   Filing an application without the majority of this paperwork simply results in a quick denial.

Secondly, as I have written about previously, Medicaid has an asset limit.  Filing an application before you’ve reached the asset limit also results in a quick denial if you haven’t spend down to the target amount.

When filing an application we can request retroactive benefits for as much as 3 months back from the month in which we file the application – as long as we prove we were eligible for those retroactive months.  Too often, however, when we get the approval, it isn’t retroactive to the date we ask for but instead, starts from the date the application was filed.

This then leads to the need to file the request for a fair hearing.  While we attempt to fix the mistake quickly without the need for an appeal, if we don’t get a quick response we need to automatically file the appeal before the 20 day deadline expires.  Otherwise, we will forever lose the right to contest that part of the decision.

When the appeal is assigned to a judge, we can then get an answer thru that court process to insure that our clients – and the facilities who actually are providing the care which Medicaid is designed to cover – receive the benefits they are entitled to. Just another reason why you have to be sure you are knowledgeable enough about the Medicaid process or are working with someone who is.