Colleen D. BratkovichMost families read a denial letter as a verdict. In Pennsylvania, it’s usually just the start of a 30-day clock.
If you apply for long-term care assistance through Medicaid — whether for nursing home care or home and community-based services — and your application is denied, the situation can feel hopeless. It isn’t. You can appeal the decision, and a denial is rarely the end of the story.
Medicaid is a program with strict income and asset eligibility requirements, and qualifying means navigating an application process with real potential for missteps. But a denial doesn’t mean you’ll never qualify for benefits. Most denials fall into one of three categories:
Missing documentation. You need to show proof of eligibility — Social Security statements, bank records, property deeds, retirement accounts, insurance records, and more. Sometimes it takes longer than expected to gather these, and sometimes the delay isn’t even in your control, especially when you’re waiting on a financial institution or insurance company to produce the records.
Excess assets. To be eligible for Medicaid benefits, a nursing home resident — and spouse, if applicable — must be below a certain asset limit.
Transferred assets. If you transferred assets for less than market value within five years of applying, you may face a penalty period before you become eligible for long-term care benefits. Technically, this isn’t a denial — it’s an approval with an assessed period of ineligibility. You’ll still be eligible for Medical Assistance generally, just not long-term care benefits during that period. If you disagree with the ineligibility period or the valuation of the transferred assets, that too can be appealed.
The Medicaid agency is required to issue you a denial notice. Read it carefully. It will explain why the application was denied and specify how to file an appeal.
The denial notice will also tell you how long you have to file — in Pennsylvania, that’s 30 days from the date of the notice. Keep in mind that date may be days, or even a week or more, before you actually receive the letter in the mail. Once your appeal is submitted, there’s typically a delay before a hearing date is set. During that time, you can keep working with your caseworker at the County Assistance Office on any outstanding issues, and if you reach a resolution, the case can be approved and the appeal withdrawn.
If the case does go to a hearing, the applicant or their representative must attend, or the case will be dismissed. Hearings are typically held by phone, though an in-person hearing can be requested. It’s a good idea to have an attorney with you through this process to make sure the correct documentation and information are presented. If you win the appeal, benefits are retroactive to your date of eligibility — usually the application date. If you lose, you can still work toward future eligibility, but without retroactive coverage you may owe a significant bill to the nursing home in the meantime. A decision can also be appealed further, to Commonwealth Court, where having an attorney is essential.
If your application was denied correctly, there are still steps you can take — spending down assets appropriately, or gathering the missing documentation — before reapplying. The most important thing to remember is that a Medicaid denial is rarely a dead end. Many applicants give up, assuming they’ll never qualify, when in fact an experienced elder law attorney can guide them through the appeals process to reach eligibility.
- If you received a Medicaid denial notice today, would you know how many days you have left to appeal?
- Do you know which of the three common denial reasons is most likely to apply to your family’s situation?
- Have you assumed a denial means starting over, rather than the start of an appeal you could win?
A Medicaid denial can feel like the system closing a door. More often, it’s the system asking for more information, or for someone to challenge a calculation — and that’s exactly the kind of fight worth having with the right guidance behind you.
For more information on applying for Medicaid benefits, contact out office at 724.942.6200 or request an appointment at ZacBrownLaw.com.
Christine Brown Murphy
