The process of qualifying for Medicaid to help pay for nursing home care can be stressful, especially when a denial notice is involved. Fortunately, this isn’t the end of the process. Several options still exist once a Medicaid applicant receives notice of an adverse action.
The first option is to simply reapply for benefits. This is ideal when the denial was based on a missed deadline. Medicaid caseworkers must review eligibility of the applicant during the previous three (3) months. For example:
Applicant files for Medicaid assistance on February 10 with a targeted eligibility date of February 1. On March 3, a denial notice is received along with an explanation that a bank statement was not submitted on time. The applicant may simply re-file the application on March 3. The caseworker will check eligibility not only for March 1, but for February 1 and January 1 as well. As long as the applicant met the eligibility standards on February 1, the case should be approved as of that date.
Using the example above, let’s assume that a second denial notice was received on May 7. The three-month look back period has passed. The applicant must appeal the decision within thirty-three (33) calendar days of the date of the computer-generated denial notice. An Administrative Law Judge (ALJ), employed by the Division of Family Resources (DFR), will preside over the fair hearing. The parties of the hearing are the person appealing (appellant) and the DFR office. The appellant has the right to be represented by an attorney, paralegal or even a lay representative. The DFR can be represented by an attorney, but it’s usually only represented by an appeals representative. The hearing itself is informal, despite the set format. The DFR presents its evidence first, through testimony and documents. The appellant has the right to cross examine any witnesses. The appellant’s case is then presented through documents and testimony. Each side can then make a closing argument. The ALJ will take the case under advisement. A written decision is always issued.
If the ALJ agrees with the DFR and upholds the original denial, the appellant may request an Agency Review, where the facts are reviewed by a designee of the DFR. The request for Agency Review must be in writing and filed within ten (10) days following the receipt of the fair hearing appeal decision. Oral arguments are not allowed in an Agency Review. A memorandum of law can be filed within twenty (20) days of the date when the ALJ decision was received. The memorandum should contain the legal argument and should serve to persuade the reader that the appellant is a real human being who needs relief. Additional evidence cannot be submitted during this stage. A written decision will be issued.
In cases where the Agency Review results in a denial, the appellant can pursue the issue by means of a Judicial Review. In order to continue the appeals process, the appellant would be best served by contacting an attorney with experience in the Medicaid appeals process as soon as possible since a petition must be filed in court within thirty (30) days of receipt of the Agency Review decision.