When we refer to “Medicaid” we are referring to a situation in which someone is in a nursing home and has spent all their money and needs to apply for financial assistance to pay for the nursing home stay. Medicaid is the federal program that will pay for long-term nursing home care if someone qualifies as being eligible to receive benefits. Here in Massachusetts, an application would be made to MassHealth, which is the entity that is responsible for administering Medicaid in Massachusetts. The application process is very difficult and, for the reasons set forth below, should involve an attorney.
First, the application must include records relating to all assets held in the five years prior to the application being completed. Bank statements, real estate documents, retirement funds, life insurance policies, income statements, etc. all must be submitted. The application and all the related documents will be reviewed, and if there are any transfers of assets that took place in the five years prior to the application, an explanation of the transfer will be required. For example, Mary, who is now in the nursing home, had work done on her home three years ago. Although copies of checks to pay the contractors were submitted with the application, a further request of what work was performed was made after the application. Whoever is preparing the application for Mary will now have to try to find invoices for all the work done on Mary’s home three years ago. Likewise, if Mary had taken money out of the bank for any reason in those five years, an explanation and proof of where the money went would be required.
Additionally, in almost all cases, the first application will be denied because some information could just not be found. If the application is denied, someone will then have to attend an appeal hearing in front of a hearing officer in order to appeal the first decision. An attorney who has experience with such hearings would be best suited to attend such a hearing. Furthermore, in some cases the nursing home will offer to prepare the application, but the nursing home will not attend the appeal hearing.
Perhaps the most important reason to have an attorney involved is to receive advice that no other person would likely be able to give. The Medicaid regulations are extensive and complicated but they do contain provisions allowing assets to be spent or transferred in very specific situations. For example, if Mary’s daughter Ann had lived with Mary for a specific length of time prior to Mary needing nursing home care and Ann had provided specific functions in connection with Mary’s care, then Mary could transfer her house to Ann without any penalty from Medicaid. There are also ways to spend money just before a person goes to a nursing home that would not cause a delay in qualification. For example, Mary could spend money to create a funeral plan and establish a burial account at the bank. Attorneys who deal in these strategies on a regular basis would be best suited to provide advice.
Finally, in some cases, the only option after submitting the application, getting denied, attending the appeal hearing, and getting denied again, is to go to court. This requires preparing and filing a complaint to detail your grievance, serving the necessary paperwork on the correct parties, getting the required documents from the correct administrative agency, and so on. Eventually, a hearing will be held at which someone will have to represent the aggrieved party. Most people would want this someone to be an attorney with experience in this situation.
As you can see, applying for Medicaid to pay for nursing home care is not simply filling out an application and sending it in to the right place. It is an extremely complicated process. An attorney should be consulted for all the reasons set forth above.