What happens when a senior residing in a nursing home has an appeal denied for medicaid?



Her application was denied. I know an appeal is next but what happens after that? I am POA, but am on disability and the lawyer has used up nearly all of the retainer, and there is no more money to pay anyone.


It would be helpful if you stated the reason that the application was denied. The first step to challenging the denial is to request a fair hearing. The request for a fair hearing must be submitted shortly after the denial in order to preserve the requested start date.

One reason for the denial could be that you did not supply the requested documents within the allotted time frame. This can be easily addressed by supplying the documents during the

time you are waiting for the fair hearing from the appeal request. As the MassHealth workers are understaffed, it happens that even though you have supplied the documents, the worker claims to have not received them. Resubmitting the documents works every time.

One reason could be that the applicant is over assets. The applicant would need to spend down to the asset level requirement. Assuming the applicant is in Massachusetts, that would be $2,000.

One reason is that the applicant made a gift during the previous 60 months from the requested start date and a disqualified period was issued. The gifted assets would have to be returned to the applicant to cure the gift, which would make the applicant over assets. Then the assets would need to be spent down.

Lastly, I have received denials for clients simply through error because the caseworker coded an asset incorrectly. A phone call to the case worker will fix that as well.
Your attorney should be explaining why there was a denial and what needs to be done to fix the problem.

The term fair hearing implies that you will be going to a court. In reality, the fair hearing officer is an attorney hired by the stated to review the MassHealth determination and your documentation. If you lose at the fair hearing level, you may then request a rehearing, and after that appeal to the court system.


Legal Disclaimer: Please note that this answer does not constitute legal advice, and should not be relied on since each situation is fact specific, and it is impossible to evaluate a legal problem without a comprehensive consultation and review of all the facts and documents at issue. This answer does not create an attorney-client relationship. A lawyer experienced in the subject area and licensed to practice in the jurisdiction should be consulted for legal advice. Circular 230 Disclaimer: Any information in this answer may not be used to eliminate or reduce penalties by the IRS or any other governmental agency.

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