There are four main hurdles for a person applying for Medicaid long-term care benefits: 1) medical eligibility, 2) providing verification to support the Medicaid application, 3) financial eligibility, and 4) transfer penalty issues. If any of these four criteria are not addressed, your application for Medicaid long-term care benefits can be denied.
Medical Eligibility. Does the applicant really need long-term care? For the person in a nursing home, this aspect of eligibility is normally satisfied. You would not go to a nursing home unless you needed that level of care, and the facility will generally not admit you. This hurdle is not usually a problem for nursing home applications. It can sometimes be more of an issue when applying for Medicaid to pay for home care. When applications are denied for lack of medical verification, it is normally because the paperwork has been delayed. There are three forms that must be completed to document medical eligibility. Specifically, the Medical Evaluation (Form MA-51), the “Level of Care Determination” and the “Long Term Care Admission Transmittal (Form MA-103). Securing these forms from the appropriate parties requires follow-up. If this paperwork is missing, the application for Medicaid long-term care benefits will be denied for lack of medical eligibility.
Verification. The caseworker at the County Assistance Office requires the applicant to prove eligibility by submitting substantial supporting verification. The “burden of proof” is on the applicant, so the applicant must supply written documents that prove that the information set forth on the Medicaid application is true and that the eligibility criteria have bene met. This documentation includes but is not limited to copies of bank and financial statements going back as far as five (5) years, copies of checks or receipts for expenditures and asset transfers exceeding $500 in any given month, current bank statements, car title, military discharge paperwork if applicable, health insurance cards, funeral paperwork and cemetery deed, marriage certificate if applicable, driver’s license, documentation of gross monthly pension and gross monthly Social Security income, copies of deeds to real estate, birth certificate or other verification of date of birth and US citizenship, explanations for gifts that exceeded $500 in total for any given month during the 5-year lookback, documentation of cash value for life insurance. “Failure to provide verification” is probably the most common reason for an application for Medicaid long-term care benefits being denied in Pennsylvania. Our office is able to help you secure this documentation if you do not have it, or need assistance.
Financial Eligibility. Once all the bank statements and verification has been provided, the caseworker reviews the assets on hand, and determines whether the applicant is under the applicable resource limit, and if applicable, what assets can be protected for the spouse who is not in a nursing home. In 2024 the resource limit for an applicant with gross income under $2,829 is $8,000, and the resource limit for an applicant with gross income over $2,829 is $2,400. The maximum community spouse resource allowance for 2024 is $154,140, and the minimum spousal resource allowance for 2024 is $30,828. An elder law attorney can often help the spouse at home protect more. In the absence of help from an elder law attorney, exceptional circumstances, or a successful appeal, Medicaid benefits will be denied for “Excess Resources” if the applicant is over their limits.
Transfer Penalties. If non-exempt gifts have occurred during the five years preceding the filing of the Medicaid application, the caseworker will normally deny benefits by imposing a “Medicaid transfer penalty.” The 2024 transfer penalty divisor is $379.65/day, so as an example, total gifting of $20,000 in the 5 years preceding the Medicaid application will likely result in a denial of Medicaid benefits for 52 days. A lawyer can identify transfers that are exempt, or appeal the transfer penalty and in some cases, you may be successful in avoiding the transfer penalty.
How to Avoid Medicaid Denials
An experienced elder law attorney who routinely handles applications for Medicaid long-term care benefits can guide you through the process. Order the medical verification ordered at the earliest moment, gather the necessary documentation ahead of time, know the rules and how to establish financial eligibility, and spot transfer penalty issues early so steps can be taken to avoid or minimize transfer penalties to the extent possible.
Please consider allowing the elder law attorneys at Gerhard & Gerhard P.C. to guide you through the Medicaid application process and help you with this paperwork. We can help you avoid mistakes, and, in many cases, you will be able to protect more assets than if you attempted to handle the process on your own.
Having an advocate to guide you through the Medicaid application process will save you time and avoid mistakes. During an already stressful time, consider hiring an attorney who is an expert in the Medicaid process. You can rely on the lawyers at Gerhard & Gerhard, P.C. to be on your side every step of the way.
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Disclaimer: We recommend that you receive ongoing legal advice from an elder law attorney before attempting to navigate the Medicaid application process. If you have questions or wish to secure our services, please contact us.
