So your application for Medicaid long-term care benefits is “pending” with the local County Assistance Office. Here are 7 things you need to know:
You or your attorney should stay in contact with the caseworker at the County Assistance Office while the application is pending.
Once the Medicaid application (Form PA-600L) has been filed, it will be assigned to a caseworker with the Pennsylvania Department of Human Services known as an “income maintenance caseworker.” This person will review your application and any supporting verification. The application will be denied if supporting verification is not received by the caseworker in a timely manner. The case can also be denied if the assets are over the resource limit, or there are gifts within the 5-year lookback that are not exempt.
Communicating with the caseworker on an ongoing basis by phone or email is important so issues can be identified and addressed quickly — before a denial notice is sent. The caseworker will be trying to learn the details of your case, but has dozens of other cases to review. Speaking with the caseworker provides the opportunity to quickly answer questions that the caseworker might otherwise have to spend significant time figuring out on their own. If you have an attorney handling the application process, they should keep you informed of all notices received, and should be actively communicating with the County Assistance Office to “follow the application” through the system.
Locate and promptly provide the documentation requested by the County Assistance Office.
The caseworker will normally send an “application acknowledgement” within 20 days of the application that sets forth what items of additional paperwork (verification) are needed. If you know there are bank statements, cancelled checks, or receipts missing, you should be working to gather these items from day one. It is best to submit complete documentation along with the application for benefits, but this is not always possible. An experienced elder law attorney will usually know what is missing before the caseworker requests it, and will be actively working to help you secure missing documentation so the application can be approved.
Know what effective date you are seeking.
An application for benefits is sometimes filed early, before the spend-down is complete. This is not necessarily a problem, but it is important that you precisely identify the effective date you are seeking with the pending application for Medicaid benefits.
If you do not know, then the nursing home may credit payments to the account in a manner that results in the wrong effective date being granted. With the daily cost of care often exceeding $500 per day, this can be expensive. An incorrect effective date can be corrected by working with the County Assistance Office, but this can take a while and the problem is normally easy to avoid by handling matters properly while the Medicaid application is pending.
Know the deadlines.
The caseworkers must generally make a decision within 45 days of the application. If you are denied benefits then you generally have 30 days from the mailing date of the denial notice in which to file an appeal. There are exceptions to the 30-day appeal deadline in certain situations, such as where the County Assistance Office might inadvertently send the notice to the wrong address or fails to send the notice to the applicant’s legal representative who was set forth on the Medicaid application. Sometimes the postmark date on the envelope is significantly later than the mail date on the notice, and this is also grounds for requesting an extension of the appeal period. (Save the envelope with the late postmark date.) Your attorney should be monitoring the application through the process and should be well aware of these deadlines.
Is your application actually still pending?
If your application for Medicaid long-term care benefits has been denied for whatever reason, it is no longer pending. Rather, it is in denied status, and is not pending. The only way to keep it “pending” is by filing a timely appeal of the denial notice. Some people continue to work with the caseworker at the County Assistance Office after receiving a denial notice – which is good – but if the case has been denied and you are beyond the appeal period then a major problem can arise. Specifically, if the case is denied and has not been appealed, the caseworker’s ability to authorize retroactive benefits is impaired.
Generally speaking, the earliest possible effective date the caseworker can grant, assuming the eligibility criteria have been met, is the first day of the third month before the month in which the application has been filed. If the application is denied and not kept alive with an appeal, you may not be able to secure retroactive benefits, which can result in a large unpaid bill with the nursing home. We call these “gap cases” where there is a gap in coverage and an unpaid nursing home bill.
Make sure you receive updates from the person helping you with the Medicaid application.
We commonly receive phone calls from potential new clients who inform us that their application for benefits has been pending for “many months” and they are concerned that it has not been approved. If it has been pending for more than two months we know that the caller’s application has probably been denied and the family has not been informed of the denial of benefits, or they did not receive the denial notice from the County Assistance Office. This is not uncommon.
Often the nursing home resident and family representative have not seen copies of any notices, and believe the nursing home business office is “handling everything.” This is a dangerous place to be, since you are not able to make sure an appeal is filed timely, or play an active role in supplying paperwork to the County Assistance Office or explaining why certain asset transfers should be exempt from the transfer penalties.
Make estimated income payments to the nursing facility.
Most recipients of Medicaid long-term care benefits will have to remit a portion of their monthly income toward the cost of care. In general, this payment will be gross income minus documented health insurance premiums, any dependent or spousal allowances, and the $60 (since 1/1/2025) monthly personal needs allowance. Paying this monthly income to the nursing facility while the application is pending is reassuring to the nursing home business office and demonstrates that you know what you are doing or have hired an experienced law firm that knows what to do.
If you have not paid the monthly income to the facility, you will be on their watch list as they become increasingly anxious about the unpaid bill that is accruing while the Medicaid application is pending. An elder law attorney can compute the spousal allowance to be deducted from income and provide advice on the estimated payment to make while the application is pending.
Those who do not make the estimated payment are usually attempting to handle this on their own, and run the risk of potentially being surprised by the amount of income eventually due once benefits have been authorized. We make the income payment calculation for our clients and recommend that they send checks, noting in the memo line of the check to reflect that it is a payment of income.
As you can see, the Medicaid application process has many phases and can be overwhelming if you are trying to navigate it by yourself. We recommend contacting an experienced elder law attorney to help you through every step of this complicated process.
