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  • Writer's pictureKaren McPhail, RN, MSN

Should I seek guidance when applying for Medicaid?

This is a commonly asked question and the short answer is YES! Let us explain more....

Applying for Medicaid is sadly not for the weak as it is a complicated, often convoluted and frustrating process for those needing to do so! If you are over the age of 65 and have a chronic condition you may sadly have to go down this path at some point to access necessary skilled nursing care. Long term care planning is an important step to take early on with a care manager to potentially prevent Medicaid conversion, explore appropriate options for care, access to entitlement programs, and other mechanisms to potentially maximize funds and impact overall quality!

Many people do not realize the intricacies of Medicaid. Many also do not understand that private insurance and Medicare do not cover long term convalescent care needs. Medicare provides episodic, short term coverage for rehabilitation, but not long term convalescent care support. There is no long term care coverage component for these programs. Medicaid pays between 45% and 65% of U.S. nursing home costs and is the primary payor in nursing homes and some ALF's. Medicaid varies by individual state - so how each program is set up in each state will determine exactly how individuals can use Medicaid to help pay for long term care services. Medicaid has very stringent eligibility requirements that factor in a variety of things such as age, marital status, assets, and place of residence. In addition, Medicaid eligibility requirements change annually. Many people wait until they are out of funds or down to less than 6 months of funds to seek guidance, which is not advised. I strongly caution against this in todays healthcare world! Planning is always the key to avoiding heart-ship. Some facilities will not accept a new resident without a minimum amount of private pay funds and this process takes time. So although sometimes difficult to discuss, planning early with a knowledgable professional is key!!!

When I am giving guidance to clients regarding Medicaid I always initially consider the following:

  • The age of the applicant.

  • Whether the individual is applying for community or nursing home benefits (Nursing home is a more rigorous process).

  • How complicated the applicant's financial situation is.

  • How much time the family or individual has available to do these forms.

  • The physical and emotional state of the individual doing forms.

  • How organized and patient the individual is and can they follow directions well.

For those over the age of 65 I always advise a consult with an elder law attorney for planning purposes to ensure all aspects are considered and any potential issues that could result in denial are resolved and discussed. This is generally worth every penny as it can head off big problems and disastrous financial consequences later.

If there are serious financial constraints and the individuals financials are straight forward, they are organized, bright, and persistent, they may however with some basic guidance be able to successfully prepare and submit the Medicaid application themselves when applying for community benefits. This is not the usual path that I support or advise as it is still risky and can result in delays and denial of benefits, but sometimes it is the only and desired option for individuals even after guidance.

However, I caution further that generally submitting an application for skilled nursing home benefits is not a good idea without an attorney's help, because Medicaid subjects these applications to additional scrutiny. Most states require a look back or examination of five years of financial records and extensive documentation. In addition, proof of all property transfers within the last 5 years: what was transferred,

proof of date of transfer, value of the resource/property at the time of transfer is also required. Missing a date, deadline, form, paperwork can have disastrous financial consequences that will cost more than seeking elder law guidance! In the Medicaid process, any unexplained expense may be treated as a disqualifying transfer of assets. In addition, many planning steps such as trusts, transfers of funds to family members or friends, and even family care agreements will be viewed as suspect unless they can be clearly explained and accounted for accurately. The Medicaid process can then be extended for months as Medicaid will continue to inquire, make requests for information, and at times require further documentation for the answers provided. These delays again can generally be more costly then hiring an attorney.

So the short answer is yes, seek guidance ideally from an elder law attorney when needing to begin the Medicaid process as you will save yourself heart ache, worry, and money over time.

Here are some additional resources to begin the process and learn more:

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