Medicaid Pending, Nursing Home Care and the Application Process

Last updated: March 06, 2019

 

What is Medicaid Pending and Why it Matters

“Medicaid pending” is the term used for when a person has applied for Medicaid, but has not yet been approved or denied benefits. This period of time can prove to be difficult and stressful. This is because in most cases, seniors require long-term care during this interim period, but they cannot afford to pay for their cost of care.

Fortunately, there are some nursing home facilities, assisted living residences, and even in-home care providers, who will accept seniors to receive services in a Medicaid pending status. What this means is that applicants are accepted to receive services / care on the assumption that they will be approved by Medicaid and the care provider / residence will be paid retroactively. Said another way, the facility and providers will be reimbursed for the cost of care of Medicaid approved benefits from the date the Medicaid application was filed. (There is also retroactive Medicaid, which allows Medicaid to pay for services for up to 3-months prior to one’s date of application, if approved to receive Medicaid). Medicaid pending allows seniors to receive care prior to Medicaid approval, and during this time, care recipients are not responsible for paying fees associated with the care received. In addition, in the case of nursing home care, the resident is also not responsible for the cost of room and board. Please note that with assisted living, Medicaid will never cover the cost of room and board. Rather, Medicaid may cover the cost of care services in this living situation. More on Medicaid and assisted living.

For the most part, it is nursing home care that one is seeking during a pending Medicaid application. Therefore, for the purposes of this article, the main focus will be on “Medicaid pending” nursing home care.

 

Who Pays the Nursing Home While Medicaid Pending

During the period that a Medicaid application is pending, nursing home residences do not receive any payments from the state for a “Medicaid pending” resident. However, residents in this status are expected to pay the majority of their income to the nursing home. This may be referred to as a share of cost or patient responsibility, which the resident will also have to continue to pay once approved for Medicaid-funded nursing home care. Residents are able to keep a small portion of their income for a personal needs allowance, which varies based on the state in which one resides. For example, as of 2019, California allows $35 / month, Texas permits $60 / month, and Florida allows $130 / month as a personal needs allowance. In addition, seniors may also deduct the cost of any health insurance premiums, such as Medicare, from their income.

If the “Medicaid pending” applicant is married and his / her spouse is not also applying for Medicaid, the applicant can transfer part (or in some cases, all) of his / her income to the non-applicant spouse. This spousal allowance is called a monthly maintenance needs allowance and is intended to prevent the non-applicant spouse, commonly called a community spouse, from having too little income from which to support himself / herself. As of 2019, in most states, the applicant spouse can transfer up to $3,160.50 / month to the non-applicant spouse.

  Following the deduction of one’s personal needs allowance, health insurance premiums (if applicable), and spousal allowance (if applicable), the remainder of the resident’s income is paid to the nursing home when an applicant is Medicaid-pending.

Some nursing homes may ask the resident’s family to pay for the full cost of care while the elder’s Medicaid application is pending. It is highly advised that the family does not make this financial commitment. (With the exception of the resident paying a portion of their income to the nursing home as mentioned above). Unfortunately, if the family does cover the cost of care in the interim, they very likely will not receive their money back once the application has been approved.

Once a senior’s Medicaid application has been approved, Medicaid will reimburse the nursing home for the period of time that a resident was in “Medicaid pending” status. Please make note that if an applicant is denied Medicaid approval, the nursing home will attempt to collect past due bills from the resident and / or family members of the resident.

 

Find Medicaid Pending Nursing Homes

To be clear, not all nursing home residences will accept persons who are in “Medicaid pending” status. In fact, it can be a challenge to find facilities that will accept persons who have not yet been accepted into their state’s Medicaid program. This is because the nursing home is taking a risk, as they cannot know for certain that the applicant will be approved. If the applicant is not approved for nursing home Medicaid, Medicaid will not reimburse the facility, and in most cases, the nursing home will simply not be paid.

In addition, nursing home facilities limit the number of beds for Medicaid-funded residents. Therefore, it is not a clear cut “yes” or “no” as far as if a nursing home will even accept Medicaid-funded residents. This is because once all of the Medicaid-funded beds are filled in a Medicaid-approved residence, they will not accept any more residents on Medicaid (or in Medicaid pending status) until a bed becomes available. Even if a nursing home residence does have a Medicaid-funded bed available, it may not accept a resident with an application for Medicaid pending.

The best approach to finding Medicaid pending nursing homes is to make a list of Medicaid nursing homes in the area, contact each one, and ask directly if they will accept Medicaid pending residents.

Once Medicaid-funded nursing homes that accept “Medicaid pending” residents have been located, persons should submit a copy of their Medicaid application, as well as documentation supporting their application (could be documentation proving that functional need, financial eligibility, residence criteria, etc. is met) to the nursing home residence. Persons should take extra caution to ensure the application is filled out correctly for the best chance of Medicaid approval.

 

How Long is the Medicaid Approval Process / Medicaid Pending

In most cases, it takes between 45 and 90 days for a Medicaid application to be processed and either accepted or denied by the state Medicaid office. However, depending on the circumstances and the state in which one resides, the application process could be shorter or longer.

Not included in this estimate is how long it takes to prepare for the Medicaid application. The Medicaid application requires extensive documents and many families spend weeks or months gathering these documents prior to submission. For persons who require long-term care, such as nursing home care, a functional assessment must also be completed. If the Medicaid application is filled out improperly and / or all supporting documentation are not submitted on time (or at all), the application process can take longer or the application may be denied. If the application is denied for lack of supporting documentation or an improperly submitted application, the process will take even longer, as one will need to start the application process all over again. If one is denied Medicaid benefits for another reason, he / she can appeal the decision. One’s denial of benefits letter will explain the appeal process.

  There are public and private Medicaid Planners that can facilitate the Medicaid application process. Learn more.   

 

Professional Medicaid Application Assistance

As mentioned previously, it is vital that Medicaid applications are filled out correctly and all supporting documentation is provided to the Medicaid agency in a timely manner. The Medicaid application process can be complicated, particularly if an applicant is married or if it is questionable if an applicant meets the income and / or asset limit(s) in the state which he / she resides.

To see state-by-state Medicaid eligibility requirements click here. Being over the income and / or asset limit(s) is not automatic cause for disqualification. Rather, the restructuring of one’s finances will be required. This is where Medicaid planning strongly comes into play. For the best chance of acceptance into one’s state’s Medicaid program, it is highly suggested one seek the advice and expertise of a Medicaid professional planner. Find one here.

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