Q&A On What If Medicaid Denies You Eligibility? 12/15/15

Intro: We've talked a lot on the show about how to protect assets and still pay for long term care costs using the Medicaid program. But what if after all the work to obtain benefits, the case worker denies eligibility? Is that the end; is there anything you can do?

Q: So, you've applied for Medicaid. After satisfying all the requests of the case worker, the application is denied. Is there anything you can do?

A: First of all, don't panic. You needed a clear head and perseverance to make it this far through the Medicaid application process, so now is not the time to panic. You just need a plan.

Q: it seems to me like the perfect time to panic. The government just denied you the only way you can afford to pay for the nursing home for you loved one!

A: Well, you do have options. You need to remember that the case workers work for a governmental agency with a limited budget. Lots of people need assistance with paying for long term care. So, there are bound to be many denials. Sometimes the case workers are overworked and don't spend enough time with a case evaluation. Sometimes a case is very complicated and the case worker doesn't understand the issues. In any event, there plenty of times that a case may be denied wrongly.

Q: So, that is allowed to happen, a case worker can simply deny and there is no recourse?

A: That is the not true, the applicant and family have many rights. Most people don't understand the foreign terms in the denial notice. First, they should talk to the case worker and ask for an explanation. If she is not helpful (many are not and won't even return phone call, especially for a denied case), then insist on talking to the supervisor for an explanation. You may be able to have them review the case and change the denial.

Q: what if that doesn't work?

A: It is not unusual for the initial denial to NOT be reversed at this level. The case workers are done with the case, and are buried with the next new case. There are appeal rights you have that are written right on the last page of the denial notice. The first level is to request a County Conference. This will allow you to officially sit down with the case worker and the supervisor and try to work out the issues.

If that doesn't work, then you have the right to request a state hearing within 90 days of the denial. The form is a part of the denial notice. You simply have to state the reason you think the denial is wrong. Simply saying the decision was wrong is sufficient. The form is sent in according to the directions.

Q: What happens then?

A: A date is set for the hearing by the State of Ohio Hearings department and you get a notice. It can be held in person or by telephone. Either way, the hearing is with a state hearing officer, the case worker and the applicant, the denied person or his representative. Everyone is sworn in to tell the truth. But still don't worry, the hearing isn't all that formal.

The case worker goes first explaining why the denial is right. Then you go next explaining why the denial is wrong. The hearing officer asks questions and finally ends the hearing.

You will get the decision within 90 days.

Q: What if you still don't win?

A: Then you can make an Administrative Appeal within 15 days of the denial at the State Hearing. This involves writing a letter to the Ohio Department of Jobs and Family Services in Columbus explaining your position. They consider it and issue a written decision within 15 days.

Q: And if you still don't win?

A: Then you can appeal to state or federal court.

Q: That sounds like a big step, do you need an attorney at that point?

A: Absolutely, that is not something you should try on your own. In fact, you really should have an attorney counsel you and work with you on the original application. That way, you shouldn't have to go through this whole appeals process. Or, even if the application is denied the first time, your attorney can handle the State hearing and the Administrative Appeal for you and make sure it's done right.

Close: Well, if you tried to apply for Medicaid and were denied, all is not lost-you can appeal. But, you should really start by working with a certified elder law attorney to try to avoid the denial in the first place. Medicaid is a government welfare program, it should be easy to apply for, but it's not.