The Medicaid application process can be complicated, confusing, and time-consuming. Any missteps in the process can result in lengthy delays in receiving an approval or denial from your county Medicaid office. Following these steps will help to make the process less burdensome, less error prone, and can reduce the time it takes to receive a determination.
Step 1 – Identify the type of Medicaid for which you want to apply
Each state has its own Medicaid program and within each state there are multiple Medicaid programs targeting different demographic groups with different eligibility criteria. For example, there are Medicaid programs for pregnant mothers, low-income families, seniors seeking assistance at home, and seniors seeking assistance in residential living environments such as assisted living communities or nursing homes. The first step is to identify the “eligibility group” for which you or a loved one is applying.
For the vast majority of seniors in most states, there are 3 relevant eligibility groups.
1) Nursing Home Medicaid – Also called “Institutional Medicaid” and provides for nursing home care only.
2) Home and Community Based Services / Waivers – Sometimes called “HCBS Waivers”. Care is provided at home, adult day care, adult foster care homes, or in assisted living.
3) Aged, Blind or Disabled Medicaid – Sometimes called ABD or Regular Medicaid. Care is provided mostly at home, and occasionally, in assisted living or adult foster care homes.
Step 2 – Determine if the applicant is “automatically eligible”
Once the specific Medicaid program has been identified, the next step is to determine if the applicant is automatically eligible for benefits or if the Medicaid candidate will need to work with a professional Medicaid planner to become eligible. Eligibility rules are complex and confusing at best. There are 3 relatively simple approaches to determine if you or a loved one is eligible 1) Read national guidelines 2) Read state specific guidelines 3) Take a non-binding Medicaid eligibility pre-screen.
A fourth, somewhat slower and more labor-intensive approach exists. One can contact their state Medicaid office and inquire. However, one should take this approach with caution. Medicaid eligibility should not necessarily be thought of as a black and white issue. When it comes to eligibility, if one does not meet the strict eligibility criteria, one should ask what can be done to become eligible. What other pathways to eligibility exist? Typically, when contacting a state Medicaid office, these alternative pathways to eligibility are not discussed. Find your state Medicaid office.
Step 3 – Gather supporting documents to accompany the application
If you determine the Medicaid candidate is automatically eligible for Medicaid, you will need to gather a significant number of documents to accompany the application. It may take some time and effort to gather these documents, as some are required as far back as 5 years preceding the application date. The list below does not necessarily include all documentation that may be requested by a state’s Medicaid agency.
|Medicaid Application Supporting Documents (Updated Mar. 2022)|
|Financial Account Statements||Most recent monthly or quarterly statements from all the applicant’s financial accounts including all bank, investments, IRAs, 401Ks and / or annuities. In addition, 5 years of quarterly bank statements for each account. Learn about 5 year lookback.|
|Social Security Administration Letter||Letter from the Social Security Administration that shows the amount of gross Social Security income & deductions the applicant receives.|
|Income Verification Letter(s) or Tax Forms||Income verification letters or tax forms that document all income streams including: wages, pensions, royalties and / or interest. These come from the payer of the income.|
|Proof of Health Insurance Coverage and Costs||Recent statement showing the amount of the health insurance premiums and documents which evidence the types and amounts of coverage such as Medicare, Part D and Supplemental Insurance.|
|Family Trust Documents||List of the items and assets in the trust and beneficiaries.|
|Proof of Life Insurance Assignment||If relevant and lists beneficiaries|
|Durable Power of Attorney||If a POA exists and letter of incompetency if POA is springing|
|Funeral Trust Document||If relevant and lists beneficiaries|
Step 4 – Identify your appropriate Medicaid office
Although Medicaid is a joint federal and state program, in most states, the responsibility for application review lies with each specific county. Connecticut is a notable exception, as all long-term services and supports applications go through one of four designated application centers. Illinois has regional offices, and Indiana delegates partial responsibility for document gathering to its Area Agencies on Aging. The Medicaid.gov national site maintains an updated list of links to state, county and regional Medicaid offices. Click here to find your local Medicaid office.
Step 5 – Complete the Medicaid application
Almost all states allow applicants to submit an application and supporting documents in person, by mail, or online through a web-based application. Most states encourage individuals to use the online application. Typically this avenue will result in a faster determination time.
Find your state Medicaid website here.
Step 6 – Waiting on your determination letter
Medicaid offices, by federal law, have a limited number of days to review a Medicaid application, make an approved / denied determination, and to notify the applicant. For persons applying on the basis of disability, this is 90 days, and for all other persons, it is 45 days. However, there is no way for applicants to enforce this law and sometimes state Medicaid offices do take longer to complete the determination process. This period in which an applicant is waiting for a Medicaid determination is called “Medicaid pending”. More information about receiving care while Medicaid pending is available here.
Step 7 – Determination letter review
When you receive your Medicaid determination letter, regardless of approval or denial, it is of vital importance that you closely review the determination letter. By some professional Medicaid planners estimates, between 25% and 35% of all Medicaid determination letters contain errors made by the Medicaid application review staff. These errors can be minor, such a calculation of the share-of-cost (or patient responsibility), or they can be more critical, like an error in the calculation of how much money one spouse is permitted to retain when the other spouse enters a nursing home. Outright denial of Medicaid benefits when the applicant is, in fact, eligible is not an uncommon error. In these cases, an appeal is required. Learn more about Medicaid appeals.