Who’s doing that Medicaid application?

An application for Medicaid to pay for nursing home care can be filed by the individual himself, his spouse, another relative by blood or marriage, a staff member of an agency of which the person is a client, the person’s physician, the person’s attorney, or a designated staff member at the nursing home. Of course, a court-appointed Guardian or Agent under Power of Attorney could also act on behalf of the applicant. Anyone other than the applicant him/herself is referred to as the “authorized agent.”  Whoever takes on that task should also accept the responsibility to monitor the file, collect the necessary verifications, take any necessary action to compel a third party to release records, file the application on time, and file appeals in a timely way. Potential legal hazards are lurking around every corner. There have been a series of cases recently involving authorized representatives which had disastrous results.

Sometimes the individual or family member appointed the nursing home or its affiliated application preparers to assemble and file the application, expecting to be relieved of any obligation to collect records. Sometimes it was the Agent under Power of Attorney or family member who started the application, but didn’t follow through due to difficulties collecting records and their own busy life. Sometimes the family member was led to believe that the County Board of Social Services would “assist with the application” by reaching out to get verifications that the family member couldn’t produce. In other cases, there were communications breakdowns between the affiliated authorized representative and the nursing home, or the representative and the family member. Either way, Medicaid eligibility is denied again and again for “failure to produce required verifications” or “failure to cooperate” with the application process. The individual is left holding the bag — with a huge debt and no source of ongoing payment — and the nursing home discovers that it has provided services without compensation.

Several recent cases illustrate the problem. The decisions are “not approved for publication,” which means they are not precedential and not binding on lower courts, but they do provide a window into what can go wrong in these situations.

In P.B. vs DMAHS and Atlantic County, a daughter of the applicant took on the obligation to file the application. The documentation was incomplete and after multiple communications to the daughter, the application was denied for failure to provide required documents.

In A.D. vs DMAHS and Cape May County, Future Care Consultants was the designated representative. The caseworker was sending his/her requests for more documentation to the nursing home, and the decision does not say anything about the communications between those two. However, the representative failed to investigate the questions at hand and therefore, did not provide the available verifications.

In V.S. vs DMAHS, (Passaic County), the Agent under Power of Attorney designated the nursing home as the Authorized Representative. The necessary documents weren’t all provided, and the application was denied. The nursing home neglected to appeal within the 20 day window, and filed the request for hearing 7 months later. DMAHS refused to grant a waiver of the 20-day appeal deadline, and this denial was upheld.

In W.S. vs DMAHS and Atlantic County Board of Social Services, the individual’s authorized representative  was the nursing home. It applied four times and each application was denied for failure to provide the necessary proofs. The Court held that the county agency had no affirmative duty to acquire the needed documents.

In J.H. vs. DMAHS and Ocean County Bd. of Social Services, the authorized representative was Future Care Associates. They failed to procure all of the necessary verifications, with the result that the application was denied.

An application for Medicaid in New Jersey requires copious financial records for every single asset owned by the individual or spouse during the 5 year look-back. Copies of cancelled checks, deposit slips, credit card statements, explanations for ATM withdrawals … everything is being scrutinized. Once the county board asks for more records, the turnaround time is pretty short.  The applicant probably doesn’t have those records lying around, and it can take months for the Authorized Representative to get the records. The Authorized Representative may not even know where to start looking, and may need help from immediate family members. It could become necessary to file a court petition to compel third parties to produce documentation.

What’s the solution? Advance preparation is vital. We encourage our clients to come in three to six months before the date they plan to apply, so there is time to gather up the necessary proofs. Also, if a family member or POA  is appointing somebody as the representative, s/he should make sure that it is crystal clear as to who is doing what, and that all necessary authorizations have been provided so that the  representative can do their job. The family member should certainly insist that the representative keep them informed of the status, including any threatened denials. And the contract with the representative should spell out the representative’s responsibilities.

Call us for advice about Medicaid eligibility, asset preservation and the application process .. 732-382-6070





Thwarted by HIPPA rules? Persevere.

Protected health information can’t be  disclosed to anyone but the patient or the patient’s authorized recipients.  If you are the court-appointed Guardian of an incapacitated person, or you are a designated Agent under a Health Care Proxy or Health Care Power of Attorney, you may have encountered roadblocks in trying to get access to the records of the person you are acting for.  These protections of confidentiality were always a matter of common law but were explicitly set down in the Health Insurance Protection and Portability Act of 1996, usually called “the HIPPA Law.” The law allows the patient to sign a HIPPA-compliant records release. The law also explicitly states that a Guardian is an authorized recipient, and that the designated Health Care Proxy/ Agent/ Representative is an authorized recipient. Nonetheless, even if you are authorized, you may hit roadblocks getting access to the medical records of the incapacitated person.

I encountered this recently and I have to say it was just maddening. I have been  the Legal Guardian [of Person and Property] for a certain individual for about 15 years. Two months ago he had a serious injury and was admitted to the hospital. The patient has been in that hospital before and I thought that my guardianship record had been placed on the chart. Arriving at the hospital on the weekend without my guardianship certificate, I discovered that they could not check the prior charts, and of course would give me no information. At 7:30 Monday morning, I faxed up the guardianship certificate with a request that the nurse or doctor call me. By mid-day  I had heard nothing and when I called in I was told that those faxes go to a central fax room and don’t get delivered right away [though I had faxed it to the direct line at the nurses’ station]. This whole process had to be repeated and finally a day later I was able to have a telephone meeting with the treatment team. Then he was back in the hospital, and on arrival at the hospital a few mornings later the floor nurse wouldn’t allow me to review the patient’s chart, citing HIPPA, and I had to again provide the certificate because they still hadn’t actually entered this critical information into the patient’s chart.   Even with that it took several conversations until the nurse was persuaded that I had authority to not only see the chart but to make the decisions and sign the Consents to Treatment. When the patient was discharged to an outside  subacute facility, the hospital didn’t provide this guardianship information with the transfer paperwork and I had to start it all over again. When he went back to the hospital, a new chart was being created and again, they found no record of my guardian status. Start again.

The usual Health Care Power of Attorney appoints a decision-maker to make the medical decisions if the doctors determine that the patient is incapable of giving informed consent. A good document will also say that its effectiveness is not diminished by the mere passage of time, and it will also grant HIPPA access to information. However, if the patient isn’t incapacitated, the patient may still have to sign a new HIPPA authorization in order for the treatment team to be willing to share information with you. That wouldn’t install the person as surrogate decision-maker at that point, but it would give them access to necessary information in order to be able to assist the patient to make decisions about treatment. Here is a downloadable PDF of a HIPPA-compliant form which we provide to all of our estate planning clients. HIPAA FORM.

The moral of this story is: (1) always bring the original guardianship certificate or health care power of attorney to the health care facility with you, (2) get an updated guardianship certificate one a year so that it is reasonably current; (3) if you are the health care proxy but your person isn’t mentally incapacitated, ask him or her to sign a medical release authorization and place it in the chart so that you can have access to information.

Call us for legal advice concerning the appointment of health care representatives and functioning as a guardian or power of attorney ….. 732-382-6070

What are HIPPA forms and why do you need them?

What is known as “HIPPA” was enacted by Congress as the Health Insurance Protection and Portability Act of 1996.  42 USC 1320d-6. https://www.law.cornell.edu/uscode/text/42/1320d-6  It is designed to protect the confidentialiy of a patient’s medical information. The extensive federal regulations are found at 42 USC part 160. http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/

A side effect of all of this good confidentiality is that  family members who are actively involved in a patient’s care can find that they just can’t get any information when they call. I ran into that at a major NJ hospital when  my aging mother was admitted for surgery. They needed the doctor to sign a document authorizing me to read the chart, and they had no form for my mother to sign to give me access. When my father was in a rehabilitation facility in NYC and could only get around in a wheelchair, he had to be taken down to the medical records office at the far corner of the basement floor of the building to find the right clerk who, if she was actually there, could give him the form to sign to give me access to information. It was ridiculous.

Attached is the HIPPA form that we give to our clients to use when they sign their estate plans.   HIPAA Form                It can be signed by the patient or by their designated legal representative. You can sign these forms and give them to every doctor, hospital, clinic, or facility you are treated at. Although they will give you a form to sign in which you acknowledge that they won’t share your information with anyone except what’s allowed by law, THIS form actually tells them who they ARE authorized to share your information with. At the top you will see a line to list the names of the people you authorize the health care provider to share information with. Put their phone numbers as well. You need to indicate the purpose (“to help me”) and whether it has any expiration date.

The HIPPA release is NOT a health care proxy. Unlike a health care proxy or power of attorney, it does not give anyone decision-making authority over you.  It doesn’t appoint a decision-maker. It is not an advance directive or “living will” or any kind of instruction directive. It merely cuts through the red tape so that your first responders and involved family members can get the information they need directly from the health care providers. If the patient is already incapacitated, the health cae proxy can sign these releases on the patient’s behalf. If a legal Guardian has been appointed by the court, they can sign these releases if they want to give another close person access to the information.

Whether managing your own health care or someone else’s, making sure that all members of the “team” can talk to each other is crucial. The HIPPA form is one of the arrows in this quiver.


For legal advice on elder care and health care crisis planning, call for appointment … 732-382-6070

Supported Decision-Making as an Alternative to Guardianship

Back on May 29-30 I participated in the 3rd World Congress on Adult Guardianship in Arlington VA and followed up with blog posts about alternative approaches to guardianship around the world. Supported Decision-Making is a concept that is gaining traction in many places and certainly deserves careful consideration here in New Jersey. It’s more complicated than merely entering an adjudication of incapacity and appointing someone as Guardian over another person. An array of agreements and release authorizations is needed, essentially combining HIPPAA releases (for immediate access to health information), perhaps a conservatorship (voluntary arrangement for management of finances with court oversight), a psychiatric advance directive (if that is an area of concern)  and agreements between the young adult and their parent/supportive adult as to how the supportive adult will assist with decision-making and safety.

For parents of young adult children with special needs, pursuing a non-guardianship approach to help their young adult with intellectual disabilities (ID)  navigate their way safely in the world can be a huge task. I just came across a comprehensive article on this subject which was exciting to read, in the Penn State Law Review.4-Kohn et al. (final) (rev2) (1) It explores every aspect of this new concept in great detail.