Elder Law: The Medicaid Application Is A Tough Process

When it’s time for a loved one to move into a nursing home, it is often a wise strategy to apply for long-term care Medicaid benefits in order to offset the burdensome costs of their stay there. However, there are many personal and financial issues to be addressed by the person who is preparing the application (usually a family member). For example, while a loved one’s income may at first seem too high to qualify for Medicaid coverage, proper Medicaid planning can legally make the applicant eligible.

Medicaid Application Process

What is Medicaid?

Medicaid is a federal health insurance program that offers various benefits to low-income individuals of any age, including elderly people who are 65 or over and young people with certain disabilities. Some of the services Medicaid covers include hospital insurance, medical insurance, and nursing home.

What are the requirements to qualify for Medicaid?

Before beginning the lengthy application process, these four requirements and considerations must be taken into account:

  1. The applicant must currently reside in the state in which they are applying for Medicaid and either be a U.S. citizen or a permanent legal resident of United States.
  2. The applicant has to be over the age of 65 (inclusive), permanently blind or disabled, or a U.S. citizen (although some cases allow for a resident alien) in medical need of licensed nursing care. Additionally, the applicant must meet the risk assessment criteria for nursing home placement, although, for this, the opinion of the applicant’s physician stating that the applicant needs nursing home care is usually sufficient.
  3. The applicant must be receiving no more than $825 per month as an individual or $1,209 per month as a couple from all combined income sources. The applicant’s asset limit must be under $2,000 if applying individually, or $3,000 if applying with a spouse. Note that these numbers are specifically in reference to New York City residents at least 65 years of age.
  4. If the applicant has received or qualified for Social Security Income(SSI), they will generally be eligible for Medicaid. The individual must have a low income level, limited assets, and either have a disability or be at least 65 years old in order to be eligible for SSI.

How to prepare for Medicaid eligibility?

One can expect a laborious effort in gathering the documentation required in support of all claims made on the Medicaid application. Be prepared to provide items such as proof of identification and citizenship, Social Security cards, legal directives like a power of attorney or guardianship order, receipts for all income sources, several months of bank statements, proof of gifts or transfers, receipts for all bills being paid for the applicant by another person, deeds to real property, including oil, gas and mineral rights, medical bills, and life insurance and burial policies. Other information may be requested by the caseworker.

All communication with the Health and Human Services Commission (HHSC) must be documented in writing and saved, including phone calls between the applicant’s representative and the caseworker. Once the application is filed, the caseworker has up to 45 days to review the application and determine an eligibility decision. During this 45-day period, be aware that the applicant must be in a “Medicaid-certified” bed for 30 days, before the application will be processed. Consequently, be ready to potentially privately pay the nursing home for a few months while the caseworker’s determination is being made. In some instances, an applicant’s family member may enter into an agreement with the nursing facility allowing the applicant to stay on a “Medicaid pending” basis if the family does not have enough funds to cover the bill. However, most nursing homes don’t do this anymore. If approved, Medicaid will pay back the nursing home retroactively for up to three months from the date the Medicaid application was filed.

Do you need help applying for Medicaid?

Simple mistakes may lead to a denied application, which could cost thousands of dollars in nursing home costs while resubmitting the application and waiting again for the caseworkers’ eligibility determination. Because of the complexity involved, it is wise to consider meeting with a NY certified elder law attorney who handles this type of work on a daily basis. At the Law Office of Inna Fershteyn, we can help your loved one enter a nursing home with the necessary personnel without breaking the bank in the process. Call us at 718-333-2394 to schedule a consultation.