Five Reasons for a Medicaid Denial

What many family members don’t understand is that a Medicaid application can result in a denial for a number of reasons, most of which can be swiftly resolved.

Reason #1: Incomplete Applications.

One of the most common reasons for a Medicaid denial is incomplete applications and missing documentation, or failing to provide supporting documentation in a timely manner.  This occurrence is more often seen when family members attempt to seek eligibility without the experience of an attorney.  It’s important to have another set of eyes review documentation before it is submitted, and ensure that all contact information is correct.

Reason #2: Too Many Resources.

While some may find this hard to believe, often times family members forget about accounts.  Or simply are unclear in what Medicaid considers exempt and what Medicaid will count.  Again, this occurrence is more often seen when family members attempt to seek eligibility without an attorney.

Typically, I recommend retaining slightly less in countable resources than what Medicaid will allow just to avoid the edge of eligibility.  For example, your state may allow a community spouse to retain $119,220 and an institutionalized spouse to retain $2,500, bringing the total allowable amount of countable resources to $121,220.  Rather than having the couple retain the full amount advise them to keep only $115,000.  This leaves room for the discovery of any small accounts that may have been forgotten over the years.

Reason #3: Disqualifying Transfers.

Someone unfamiliar with Medicaid qualification criteria is likely unaware of the actions that will result in Medicaid penalty periods.  Many online message boards are filled with family members asking if they can transfer their institutionalized mother’s home to themselves to protect it from estate recovery, or if they should transfer bank accounts to themselves to reduce countable resources.  Not only is there an (understandable) lack of knowledge amongst family members, there is no shortage of incorrect advice provided in return.  Again, a prime example of why it is of the utmost importance to involve an expert in the field.

Reason #4: Not Medically Qualified.

Most states have financial requirements and non-financial requirements as far as establishing Medicaid eligibility is concerned.  The non-financial requirements usually consist of residency, immigration status, U.S. citizenship, and medical – must be aged, blind, or disabled.   And that’s just for long-term care Medicaid benefits provided in a nursing home.  States also have their own waiver programs, which provide benefits to those in the community or in assisted living facilities. The eligibility requirements for those can be vastly different.

Reason #5: Misunderstanding by Medicaid Caseworker.

This cause of denial is the most common that my office sees.  Caseworkers are everyday people that are often underpaid and overworked.  They’re responsible for anywhere between 5 to 50 eligibility determinations at any given time.  In making a determination, they may misunderstand the facts of the case, or misinterpret the rules.

Then what?

Having a good relationship with your caseworkers will often alleviate the chance of being denied, or at the very least increase your chance of being able to resolve issues at the caseworker-level.  However, don’t hesitate to contact my office for assistance.  We’re here to help.

David Wingate is an elder law attorney practicing in Frederick and Montgomery Counties, Maryland. The elder law practice consists of estate planning – wills, trusts and powers of attorney; Medicaid and asset protection planning.