The process to apply for MLTSS/Medicaid to pay for in-home care, nursing home care and assisted living is grueling. There’s no denying that. Producing all the records to the County Board of Social Services, and explaining every single financial transaction that occurred during the 60 month look-back period, can be brutally difficult, if not downright impossible. As you can imagine, sometimes, applications are wrongly denied. The County might misapply the law, disregard the evidence, or ask for documents that don’t exist. The result can be an erroneous decision. Here is a sampling of errors you might encounter: (1) a house is valued at “X” when it should be valued at much less due to the mortgage; (2) a gift should be exempt from penalty. but the exemption is denied; (3) something with no value is counted as an asset; (4) the county applies a new interpretation of the regulations which contradicts the federal law. There are many other examples.
The result of these errors could mean tens of thousands of dollars of liability for nursing home bills. It’s especially a problem when the applicant has a spouse living in the community, who can remain liable for that bill.
What’s the remedy for a denial of the Medicaid/MLTSS application? The applicant can file an appeal called a “Request for Fair Hearing,” within twenty days. This must be filed in order to protect the right of appeal.
Here’s an example of a major error that, fortunately, was reversed in the appeal process. Under federal law, if a person transferred assets as a gift during the look-back period, generally he will be “penalized” for the transfer. Let’s say he applies for Medicaid/MLTSS for June 1st because he’s in a nursing home and meets all of the requirements for eligibility [clinical need; income; and resources]. And let’s say he made gift transfers of $50,000 to nieces and nephews several years prior, during the look-back period. The result should be that eligibility is approved for June 1st, but that he receives a penalty period of approximately 5 months for those earlier gifts. The penalty period starts to run on June 1st. When it’s over, MLTSS can start paying for the care. In the case of Z.P vs Middlesex County Board of Social Services (2017), gifts had been made during the look-back period. He applied for Medicaid for a certain date and he clearly met the criteria [clinical need; income; and resources] as of that date. It took awhile for the County to process the application. After the initial date that was sought, circumstances occurred in which he would not have been eligible had he been applying for a later date. The County Board refused to trigger the penalty as of the initial date and instead, said that the penalty wouldn’t start until 7 months later, leaving seven additional months of unpaid bills for the applicant. The decision was appealed.
The Administrative Law Judge looked at the overriding federal law and found that the County did not have the option to postpone or “toll” (interrupt) the penalty period based on what occurred after that initial date when the applicant met all the criteria for eligibility. Fortunately, the State Medicaid Director affirmed, as the federal law was explicit.
Contact us promptly if your MLTSS Medicaid application is denied, as there may be remedies if it was wrongfully denied. Watch your deadlines, and act fast. Call for appointment …………… 732-382-6070