Medicaid Pending, Nursing Home Care and the Application Process

Last updated: February 14, 2022

 

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 can 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.

There are some nursing home facilities, assisted living residences, and even in-home care providers, who will provide services for seniors in a Medicaid pending status. This allows applicants 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. Care recipients are not responsible for paying fees associated with the care received during “Medicaid pending”. For nursing home care, the resident is not responsible for the cost of room and board either. Please note that with assisted living, Medicaid will never cover the cost of room and board. More on Medicaid and assisted living.

It is generally nursing home care that one requires while a Medicaid application is pending. Therefore, the focus of this article is “Medicaid pending” nursing home care.

 There is also retroactive Medicaid. This allows Medicaid to pay for services for up to 3-months prior to one’s date of application, if approved to receive Medicaid. Learn more here.

 

Who Pays the Nursing Home While Medicaid Pending

Nursing home residences do not receive 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 is called a share of cost or patient responsibility. Even after approved for Medicaid-funded nursing home care, one must contribute most of their income towards nursing home costs. Nursing home residents are limited to a small personal needs allowance. This amount is state-specific. For example, in 2022, the personal needs allowance in California is $35 / month, Texas allows $60 / month, and Florida allows $130 / month. The cost of health insurance premiums, such as Medicare, may also be deducted from their income.

If the “Medicaid pending” applicant is married and their spouse is not also applying for Medicaid, the applicant can transfer part (or in some cases, all) of their 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 becoming impoverished. In 2022, most states allows the applicant spouse to transfer up to $3,435 to their non-applicant spouse.

 Following the deduction of one’s personal needs allowance, health insurance premiums (if applicable), and spousal income 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. If the family covers the cost of care in the interim, they very likely will not be repaid once the application has been approved.

Upon approval of a senior’s Medicaid application, Medicaid will reimburse the nursing home for the period that a resident was in “Medicaid pending” status. If an applicant is denied Medicaid, the nursing home will attempt to collect past due bills from the resident and / or their family members.

 

Find Medicaid Pending Nursing Homes

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 be certain that the applicant will be approved. If the applicant is denied nursing home Medicaid, Medicaid will not reimburse the facility, and in most cases, the nursing home will simply not be paid.

Nursing home facilities also limit the number of beds for Medicaid-funded residents. Therefore, it is not a clear cut “yes” or “no” as to if a nursing home will even accept Medicaid-funded residents. When 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 (i.e., 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

It generally 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. Extensive documentation is required 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 these reasons, 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.

Determine Your Medicaid Eligibility

Get Help Qualifying for Medicaid