While Medicaid denial rate statistics are not easy to find, attorneys, (being the problem solvers of the system), tend to see a disproportionate number of MassHealth application denials. In fact, unfortunately some of our clients come to us for the first time after they have been denied. So what are the applicant’s options when a Medicaid application for long term care is denied? Below is a chronology of the Medicaid application and appeal process in Massachusetts.
I. MassHealth Application is Filed
Medicaid benefits will be paid via MassHealth to the applicant from as far back as three months prior to the month when MassHealth received the application. So if the application was received on August 31, the applicant can be eligible for benefits beginning in the three prior months, including all of May, June and July.
II. The MassHealth Request for Information
It is quite common for the applicant to receive a request for additional information from MassHealth within a few weeks of submitting the application. Many times the MassHealth case worker at the regional Enrollment Center (“MEC”) finds a discrepancy or omission that needs clarification. Common examples include property valuations or transfers of funds over $1,000. Most frequently, however, the case worker sends out this form merely to request items listed under “Long-Term-Care Information,” e.g. that the long term care facility should request a screening to determine that the applicant is physically eligible for Medicaid. The MassHealth Request for Information form is basically in a checklist format with room for the case worker to write specific directions.
III. The MassHealth Denial Notice
This is the first Notice the applicant will receive that indicates there is a significant problem with the Medicaid application. It will often include a statement requiring that a certain piece of omitted information be provided, and perhaps that an “ineligibility period” will be imposed based on an disqualifying transfer of assets during the Medicaid 5 year look back period. Other information provided on the Denial are citations to the regulations that were used to make the decision (e.g. 130 CMR 516.006).
Reasons for a denial will vary, and this notice should be read carefully. Sometimes there is a valid reason for the decision, but many times there isn’t. Keep in mind that the Mass Health rules on disqualifying transfers operate in a guilty-until-proven-innocent manner, and that the experience levels of Mass Health case workers (those that review the applications) vary quite a bit. These factors combined can lead to unfair consequences for the novice applicant.
The applicant has two options after receiving a denial. She may send in the requested information (thereby resetting the application date for purposes of receiving past benefits to the date of receiving new information), and hope for the best. But she may also request a fair hearing that works to appeal the decision. Depending on the nature of the information requested and the need to “preserve the application date” the applicant may want to do both.
IV. The MassHealth Fair Hearing
A MassHealth Fair Hearing is the last administrative remedy available to the applicant wishing to receive benefits from Medicaid. In order to request a fair hearing for Mass Health, the applicant needs to file her request within 30 days of receiving a decision on benefits (e.g. the denial notice). This is where the applicant can make the case that benefits were not received, or that a decision by MassHealth was made in error, or that the facts underlying the decision were incorrect. The hearing is conducted by a Mass Health hearing officer at the enrollment center for the applicant’s region.
Convincing Mass Health to rule in the applicant’s favor usually requires a solid understanding of the rules and how they are interpreted. The appellant-applicant should be prepared with a concise narrative of her case on why the decision should be modified or overturned. If the applicant did not use an attorney to assist with the application, contacting a Massachusetts Medicaid attorney at this point should be a priority. The cost of losing benefits is simply too great, and the attorney’s expertise will help in a number of ways, for example:
- Illustrating why a disqualifying transfer actually qualified within the rules
- Knowing when it is necessary to bring witnesses for corroboration.
- Determining what types of new evidence will illuminate the foundation for the appeal.
- Identifying whether the Mass Health denial complied with statutory requirements.
- Knowing how and why to ask the hearing officer to keep the case open.
V. Judicial Review of a MassHealth Decision
After all administrative remedies are exhausted, there is a possibility for judicial review of the decision in the courts. Of course coming to this stage of a MassHealth application is very undesirable due to the finality, expense and time of the proceedings. Similar to the limitations on an appeal from a MassHealth denial to a Fair Hearing, judicial review must be filed within 30 days of a Fair Hearing decision.
