Medicaid Denial

Author: Wolfe Ossa LawCategories: Elder Law

Medicaid, the federally mandated program that provides health care to qualifying, low-income residents across the United States, is administered at the state level. The application procedures and requirements vary from state to state. As with the majority of government programs, there are certain very specific eligibility requirements a person must meet in order to qualify for coverage.

Medicaid coverage will extend to basic health care costs that include hospital stays and doctor visits in addition to long term care, which includes care provided in nursing homes and assisted living facilities. These benefits are often critical to many Americans. The prospect of having a Medicaid application denied can cause great anxiety as a denial of Medicaid benefits can be financially devastating. There are many different reasons for Medicaid denial. Some are more common than others; others may be resolved faster than others.

Reasons For A Medicaid Denial

There are different reasons for Medicaid denial. Some of the reasons for denial may be remedied and the applicant can fix the problem to receive benefits, albeit delayed. For instance, one of common reason for Medicaid denial is having an incomplete application. A Medicaid application requires fairly extensive documentation which includes:

  • Bank statements
  • Investment account statements
  • Life insurance policy information
  • Retirement income information
  • Asset and other property information
  • Tax returns

These documents are required in order to determine financial eligibility for Medicaid and are a critical part of the application. Sometimes the failure to submit documentation is an oversight and the applicant was simply not aware of the guidelines as to what documentation is required of the Medicaid application. Medicaid could determine that the failure to submit the proper documentation is actually a failure to cooperate and can deny your application for this reason. The applicant will still be able to start the application over, but there may be a significant delay in the eligibility date for Medicaid.

Other times, it is not the applicant who makes the mistake, but the Medicaid caseworker. Medicaid caseworkers are not infallible and make mistakes just like everyone else. Sometimes a caseworker may lose documents or misinterpret one or more of the rules. Other times they will improperly advise an applicant. Medicaid caseworkers are often overextended in their work duties and this can result in Medicaid application processing errors.

Failure to meet the financial need requirements of Medicaid is also a common reason for Medicaid denial. A person may mistakenly believe they meet the income threshold to qualify for Medicaid and proceed with a Medicaid application. This mistaken belief can be due to something like being unaware of what is and what is not exempt for Medicaid income calculation purposes.  In other instances, a person may actually have assets they are unaware of or have forgotten about.

Another often seen reason for denial of benefits is the applicant may have made unqualified transfers of assets. If a Medicaid applicant has transferred or disposed of countable assets within 60 months of applying for Medicaid, the transfer will be thoroughly examined. If an asset was sold or given away for less than its fair market value it is likely to result in the applicant  being disqualified for Medicaid benefits or the imposition of a period of ineligibility. This rule is in place so that applicants do not intentionally dispose of or give away property for the sole purpose of qualifying for Medicaid benefits.

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