Medicaid, a needs-based health program for Americans and legal, permanent residents, is funded by both the state and federal governments, and covers the medical expenses of those in the community and in nursing homes. The federal government sets broad guidelines, and then each state sets its rules within those guidelines. Accordingly, it is important to recognize that each state’s rules may vary; however, for the purposes of this article we will discuss the New York view. Currently, Medicaid pays for approximately 60% of the medical costs for all nursing home residents.
The first step in the process of obtaining Medicaid is the preparation and submission of the basic form, which, if you require institutional coverage, must include the Access New York Supplement A. These forms can be obtained over the internet (New York State Department of Health website) or by telephone request. In addition, documentation proving age, citizenship, residency, marital status, income and resources should be submitted contemporaneously with the forms; photocopies are fine. We would urge all applicants to oversee this process personally; handing over this job to a caseworker in a health-care facility may not benefit the applicant, ultimately. Since the Medicaid program is needs-based, there are asset limitations. Assets include income (pension payments, social security, bank interest and the like) and resources (bank accounts, insurance, brokerage accounts and the like.) In order to qualify for benefits, the Medicaid applicant’s monthly income may not exceed $825.00 and resources may not exceed $14,850.00.
Once the application is submitted to the local Medicaid office, then a caseworker is assigned. He will commence his investigation based upon the documents and forms submitted. It is expected that the applicant will cooperate with the caseworker, and when a request is made for additional information then the applicant will provide what is requested. Failure to cooperate will result in a denial. The application process, which includes the submission of required forms and supporting documentation, is contingent upon the type of services that the applicant seeks.
Medicaid Home Care
When applying for Medicaid home care, also known as personal aide services, within the City of New York, a physician-prepared form M11q must accompany the application. It is crucial that the applicant select a physician with relevant experience in both geriatric medicine and in completing this form. Even better is the physician who will provide a supporting affirmation with the M11q. Once the physician’s report is received by Medicaid, a caseworker is dispatched to the home of the applicant to evaluate his needs on-site. If approved, then a determination must be made as to the number of hours and days per week that Medicaid will cover the medical costs for the aide. Twenty-four hours a day, seven days per week coverage is rarely approved, absent truly extraordinary circumstances.
Medicaid Institutional Care
In a sense, this application is somewhat less onerous for the applicant than the home care application as her very presence in a facility for long term care proves medical need. In addition to the basic application and supplement, the applicant will have to provide a MAP 648 nursing home form, MAP 751 consent, and Medicare Buy-In Eligibility Review Form.
Notification of the Decision
If the application is granted, Medicaid notifies the applicant, in writing, with a budget that explains the Medicaid coverage in detail. Ordinarily, Medicaid recipients can expect to receive a recertification form six months after the date of acceptance, which must be filled out and returned in a timely manner to keep benefits on-going. An initial acceptance grants Medicaid coverage for a maximum of three months retroactive from the date of the application.
If the application is denied, the applicant should request a fair hearing appeal if she believes an error has been made by Medicaid. It is important to file that request within sixty days of the denial because by doing so the applicant preserves the original application date and its retroactive period, a period of coverage that would be lost if an entirely new application was submitted.