What to do when a Medicaid Application is wrongfully denied
The process to apply for MLTSS/Medicaid to pay for in-home care, nursing home care and assisted living is grueling. There’s no denying that. Producing all the records to the County Board of Social Services, and explaining every single financial transaction that occurred during the 60 month look-back period, can be brutally difficult, if not downright impossible. As you can imagine,...
Watch out for the Rules of Evidence in Medicaid appeal hearings
The first level of appeal when the State Medicaid Agency issues an adverse decision is called a “Fair Hearing” and takes place at the NJ Office of Administrative law (OAL). The Judge is referred to as an Administrative Law Judge or “ALJ.” That Judge issues an initial decision that is subject to review and final decision by the NJ Division of Medical Assistance and...
Nursing Home resident on Medicaid gets second chance to win her bid for a medically necessary power wheelchair
When an individual resides in a nursing home and receives Medicaid benefits, the facility is paid an all-encompassing per diem rate which is designed to cover all of the costs of medically necessary services that the facility provides to the resident. There are times that a facility declines to provide some specialty service or equipment because of its extra cost, or the facility seeks...
Medicaid Eligibility – What if the Services aren’t delivered?
After a Medicaid long-term care application is approved and the Plan of Care (PoC) for home and community-based services is approved (MLTSS-HCBS), the individual may be faced with a wait. The New Jersey Medicaid HMO’s that provide the services for the State of New Jersey are required by the State contract to have a deep enough provider pool to service the need. However, clients are...
Transfers during the look-back merely raise presumption of intent to qualify for Medicaid
When a medicaid application is processed, five years’ of transactions are examined, and among other things, they look to see if there were uncompensated transfers or “gifts.” The agency then must presume that the transfers were made for the purpose of expediting eligibility, and can impose a transfer penalty for the gifts. You are entitled to a Fair Hearing at the Office of...
Appeal of a Medicaid Denial Must be Filed within 20 days of Notice
When an application for Medicaid benefits is filed with a County Board of Social Services in New Jersey, it may be many months before the applicant hears back from the caseworker who is processing the application. If the applicant is in a nursing home or is suffering with Alzheimers Disease or other dementias it is crucial that they have a representative such as a family member, agent under...