Medicaid Applications and Medicaid Appeals

I. Medicaid Applications

Before filing a Medicaid application, the Law Office of Donald D. Vanarelli prepares a comprehensive evaluation of each client’s unique family and financial situation. Based upon the evaluation, the Law Firm provides planning recommendations which are custom-made for each client. The planning recommendations are designed to achieve three goals: (1) to ensure that the care needs of all of our clients are provided for; (2) to make certain that there are sufficient assets available to pay for all needed care; and, (3) to ensure that the client’s estate is preserved for the client’s loved ones to the maximum extent possible. In addition, the Law Firm is available to prepare the Medicaid application and represent the client’s interests through the often lengthy administrative process. At the client’s request, the Law Firm will handle all communications with the Medicaid agency, thereby removing the client from the tedious and often frustrating application process.

Properly completing a Medicaid application and providing all necessary information and documentation to the Medicaid agency is a labor intensive process. The process, though complex, appears to be much simpler than it actually is. By assisting the client with the process, and by coordinating efforts with the nursing home or other care facility, the Law Office of Donald D. Vanarelli helps the client avoid being denied Medicaid benefits and obtain a quick approval from the Medicaid office. A quick approval after the Medicaid application is filed is very important, because the applicant and family will continue to pay catastrophic nursing home costs (which may exceed $9,500 per month in northern New Jersey) until Medicaid eligibility is attained.

Filing the Application

Federal and state laws regulate the Medicaid application process. The federal law governing Medicaid applications is set forth in the Code of Federal Regulations, 42 C.F.R. §435.900. State regulations concerning Medicaid applications are found in the New Jersey Administrative Code, Title 10, Section 71. Internal agency memoranda, called Medicaid Communications, from the state agency to the county welfare board, must also be consulted.

Extensive documentary evidence and information is required by the Medicaid agency. Because the evidence required is so extensive, personnel from the Law Firm visit the client’ at her home in order to assist with the procurement of the required information. If requested, the Law Office of Donald D. Vanarelli can also assist the client in obtaining the necessary information from the client’s financial institutions, CPAs, financial planners, insurance providers, health care managers, and other relevant representatives. We can also help in obtaining appropriate documentation from the Registrar of Vital Statistics and other necessary investigations, including reviewing the past 60 months of financial accounts and transactions.

The application must be in writing on a form prescribed by the Medicaid agency. The application must be filed in the Department of Social Services of the county in which the applicant resides. The applicant’s agent or family member may file the Medicaid application on the applicant’s behalf. However, the applicant (or his or her agent) should avoid filing a Medicaid application during the look-back period if gifts were made which would result in a penalty, or a period of ineligibility, for Medicaid. Further, the applicant should avoid committing a criminal offense by filing the Medicaid application at the appropriate time. .

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Verifications Required for Medicaid Applications

In a typical Medicaid application, the following information and documents are required, and must be provided to the agency along with the application:

Personal Information

1. Birth Date/Citizenship Information
Birth certificate, baptismal record, passport, voter’s registration card, naturalization papers, or alien registration card.

2. Marriage Certificate/Divorce Papers/Death Record
Copy of marriage certificate
Copy of divorce papers, if divorced
Copy of death record, if spouse is deceased.

3. Social Security Card

4. Health Insurance Card
A copy of the Medicare Card, front and back, is needed in addition to any supplemental coverage such as AARP, prescription cards, Blue Cross, major medical, etc. A copy of medical coverage premium invoice is also required.

Finances

5. Bank Statements
Submit the following for all bank accounts (checking, savings, CDs, IRAs, etc.) that were open at any time during the past 36 months (even accounts now closed) and that were in the names of either spouse or held jointly with someone else:

  1. Bank statements for each month for the past 60 months
  2. Passbooks covering the past 60 months
  3. Canceled checks for $1,000.00 or more for the past 60 months
  4. Provide an explanation for all transactions of $1,000.00 or more
  5. Continue to provide statements received between the application date and the date your case is granted by the state.

6. Records of Stocks, Bonds or other Assets
Verification of ownership and current value of any stocks or bonds you own alone or with another, including 60 months of statements for any stock or mutual funds.

7. Sources of Income
Written verification of all sources of income such as Social Security benefit statement, earnings, pensions, retirement benefits, Veterans benefits, SSI benefits, IRAs, 401K plans, interest income, income from rental property. GROSS AMOUNTS are required.

Property

8. Deeds
Deeds for all property owned by applicant, such as residence and burial plot, including property the applicant owns but on which the applicant does not live. If property is on the market to be sold, a copy of the Listing Agreement is needed and a Plan of Liquidation must be completed.

9. Copy of Tax Bill for all real estate.

10. Property sold in the past 60 months
A copy of the settlement sheet is needed to verify date of sale and amount received.

11. Vehicles
Registration and Fair Market Value for all vehicles, even exempt vehicles, and amount owed, if any. Include automobiles, boats, trucks, camper trailers, etc.

Life Insurance

12. Life Insurance Policies
All life insurance policies, preferably a copy of each policy itself to use as written verification of the face value. The applicant will also need written verification from the company of the current cash value of all policies. If the policy has been surrendered, the applicant must provide written verification that the policy is no longer in force.

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Legal Documents

13. Trusts
Documents pertaining to any Trust of which the applicant or the applicant’s spouse is the beneficiary or that the applicant or the applicant’s spouse have established for the benefit of any other person.

14. Guardianships / Conservatorships
A copy of the Court Order if a Guardian or Conservator has been appointed for the applicant.

15. Power of Attorney
A copy of any existing power of attorney for the applicant.

Transfers/Gifts

16. Gift/Transfer Documentation
Written documentation of all gifts or property transfers within the past 60 months. This should include a statement of date of transfer, the name of the person receiving the transfer, type of resource transferred, and resource value at time of transfer. If a transfer of real property has occurred, the applicant must provide the deed or other transfer documents and an appraisal of the property as close to the time of transfer as possible.

Miscellaneous

17. Safe Deposit Boxes
Listing of all contents of all safe deposit boxes.

18. Funeral Arrangements
Copy of funeral arrangements, if any. This must be an Irrevocable Trust Fund.

19. Income Tax Returns
Copies of income tax returns for last three years with 1099s.

20. Nursing Home Statements
Statement from nursing home verifying personal needs account balance.

Follow-up requests by the Medicaid agency for additional information and documents are common. An applicant’s timely response to agency requests is essential.

Post-Filing Issues

After the application is filed, the agency verifies information provided by the applicant by matching the information on the Medicaid application with data obtained from the I.R.S., and contacting financial institutions and other third parties. Although the verification process continues after the application is approved and may take years to complete, applicants must be scrupulously honest on the application and the verifications provided to support the application.

The Medicaid agency usually takes 2 to 3 months to process the application. However, it is not unusual for applications to take much longer to process if the application is complex or the agency is backlogged at the time the application is submitted. During the time the application is being processed, the applicant is not required to continue paying the nursing home. However, the applicant must turn over all of he applicant’s income to the nursing home. Failure to do so may result in the application being denied by the agency.

To ensure that the application is processed smoothly, it is advisable to keep the nursing home advised of the progress of the Medicaid application. Further, it is important to coordinate certain events with the facility, such as requesting that the Medicaid agency schedule a medical evaluation of the applicant through a process called pre-admission screening (“PAS”) by a nurse. Without being medically approved by the PAS nurse, the applicant cannot be found eligible for Medicaid, and the application will be denied.

 

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