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UNDERSTANDING THE PROCESS

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Medicaid or Medi-Cal applications, regardless of the state, follow a very similar four-step process. These steps are as follows:

 

1.       Submission: The first stage of the Long-Term Care Medicaid application process is the development and submission of the patient’s Long-Term Care Medicaid application. Depending on the state you are applying for benefits in, this application can be completed on paper, on your State’s official website, or by simply going in to your local Department of Health and Human Services office to speak with a case worker. Once an application for benefits has been submitted, again varying on the state, the Department will have approximately 45 to 90 days to completely process the application and slate a decision. But before they can do so, your caseworker will reach out to you and request additional documentation. This is called the Verification Process.

 

2.        Verification: In order to verify that the questions on the application for benefits were answered truthfully, the Medicaid Department will ask for documents to substantiate your claims. Long-Term Care Medicaid has a look back period of 60 months (or 36 months in the case of Medi-Cal in California). Everything that has occurred within this window of time is eligible for the caseworker’s scrutiny. Current statements pertaining to all financial holdings, sources of income, insurance premiums and a litany of other documents will be requested in order to provide the State with all the necessary information they will require in order to make a prompt and accurate assessment. Failure to supply requested items to your caseworker within the stated time period on their request WILL result in the denial of the application, causing the claimant to have to start the process over again. Once all the requests for information have been satisfied, we will move on to the Decision Phase of the application process.

 

3.        Decision: As stated above, depending on your state, the Long-Term Care Medicaid caseworker will have between 45 and 90 days to request information and eventually approve or deny the application based on their assessment. If the application is approved, it’s important to make sure that no unnecessary penalty periods have been applied and that the Patient Liability amount (the amount that the patient pays that is NOT covered by Long-Term Care Medicaid) does not exceed their total income less all health insurance premiums. In the event that an application is denied, or the Patient Liability is too high, the patient has 30 days to request a Fair Hearing to attempt to have the denial overturned. The hearing can take up to 90 days to complete but will give the patient an opportunity to speak with an administrative law judge to voice any concerns and to plead their case. Once the application is approved, a State worker will contact the patient to set up their preferred health plan. After this, the last step won’t need to be completed until later, but it is just as vital as the others.

 

4.         Re-certification: In order to make sure that the patient’s physical, medical or financial situations haven’t changed too much, each state employs their own Re-certification process. This can occur anywhere between once per year and once every five years, again depending on the state. Unilaterally, this stage tends to be the least time intensive, as the majority of documents required for approval will likely still be on file, lessening the workload of the patient. Further, since most of the information they will request in order to make their assessment will be relatively recent items, gathering required documentation should be a much easier. Conversely, improperly filing re-certification documents can and will cause the patient's Long-Term Care Medicaid services to be discontinued, forcing the applicant to re-apply and start the process over again.