Many families who cannot sustain the monthly rates of over $10,000 per month on average for a semi-private room in a facility must turn to Medicaid benefits to cover the cost of care.Planning for long term care is increasingly difficult as nursing home costs, as well as the cost of long term insurance continue to rise. Medicaid covers the full cost of nursing home care for eligible individuals. Those who receive Medicaid coverage must forward their income each month (minus a small amount of spending money) to their nursing facilities.
Eligibility rules for Medicaid are extremely strict, and the process is sometimes lengthy and frustrating. On occasion, an attorney may file a request for an agency hearing to enforce the Medicaid applicant’s rights. Denials of Medicaid eligibility are extremely common reasons to request a hearing with the Medicaid office, especially when an applicant or a spouse has gifted away assets, but there are several other situations which call for a hearing.
Below are three of these common issues that require a hearing even when the Medicaid application has not been denied.
1. To increase the healthier spouse’s monthly income. Generally, the institutionalized spouse’s income must be directed to the nursing facility; however, if the healthier spouse who is living in the community has income below certain levels, that spouse can receive all or a portion of the institutionalized spouse’s income each month. Additionally, if the healthier, or “community,” spouse can demonstrate “exceptional circumstances resulting in significant financial duress,” he or she can keep even more income from the institutionalized spouse’s monthly checks. For instance, large debts can be shown to prove that the community spouse would be deprived of food, shelter, or other basic necessities if he or she did not receive a larger portion of the institutionalized spouse’s income.
2. To increase the healthier spouse’s permissible asset allowance. Medicaid imposes limitations on the value of the assets that a spouse of a Medicaid applicant can retain. Most assets are considered countable, although certain types of assets are categorically exempt from being counted. In certain cases where the spouses’ combined income checks are inadequate to comprise the full amount of the income allowance for the healthier spouse, the healthier spouse may be permitted to retain additional assets to make up the difference.
3. To enforce a processing deadline. Although the law requires the counties to process Medicaid applications with reasonable promptness, the Medicaid agencies often miss their deadlines. Federal law establishes a processing deadline for Medicaid applications on behalf of disabled individuals of 90 days. States sometimes have shorter deadlines.
As long term care is sometimes a necessary part of our lives, it is unfortunate that the Medicaid application process often calls for applicants to jump through procedural hoops such as administrative hearings. For this reason, all applicants must educate themselves on their rights throughout the entire application process.