Filing an Application for Medicaid

I’ve been filing Medicaid applications for clients for nearly a quarter of a century.  In that time, I’ve filed hundreds, if not thousands, of applications for Medicaid benefits.

Medicaid is a federal-state health payment plan for needy individuals.  In order to qualify for Medicaid benefits, an individual must be “needy.”  Needy equates with both financial need (the Medicaid beneficiary must be without financial means to pay for his care) and clinically needy (the Medicaid beneficiary must need care with his basic activities of daily living).  Once a person establishes need, Medicaid will assist with the payment of his long-term care costs—nursing home care, assisted living residence care, or home care.

The Medicaid program is a federal and state cooperative program.  Every state participates in the Medicaid program, but participation in the program is voluntary, a state does not have to participate in the Medicaid program.  Once a state agrees to participate, the state must follow the rules of the Medicaid program.  In consideration of a state agreeing to follow the rules, the federal government will share the costs of the Medicaid program with the state.  That cost share varies from state-to-state.

In some states, the federal government covers 50% of the costs of the Medicaid program.  In other states, the federal government covers substantially more than 50% of the costs of the program.

In New Jersey, the Division of Medical Assistance and Health Services (DMAHS) administers the Medicaid program.  DMAHS contracts with the various county boards of social services to accept and review applications for Medicaid benefits.  An individual files their application for Medicaid benefits with the county board of social services for the county in which he resides.

By federal and state law, a county has forty-five days to process an application for Medicaid benefits.  I always advise my clients that despite this law, which is mandatory, expect the application process to take between four to six months.  The county can always say that it needed more information and was waiting on that information from the applicant and that’s why the application took longer than forty-five days to process.

While in many cases this is accurate, I have also had applications that sit for weeks or months without any action or request from the county.  Currently, for some applications, it takes weeks, if not more than a month, before an applicant hears from the county after filing his application for Medicaid benefits.

DMAHS promulgates rules regarding the administration of the Medicaid program in New Jersey.  Sometimes, these rules have a degree of formality and are issued through letters called Medicaid Communications.  Sometimes, these rules are less formal and are simply promulgated at meetings between the state and supervisors from the various county boards of social services.

One informal rule that currently exists is the following:  The county will issue one letter requesting additional information and the applicant has fourteen days to provide the county with the requested information; if all of the information is not provided in the fourteen days, then the application will be denied.

One problem with this rule is, letters from the county often take a week or more to reach the recipient, so by the time the Medicaid applicant receives the letter, he only has a week or less to get the requested information to the county; and the requested information can often be both extensive and difficult to obtain on short order.

Filing for Medicaid is stressful and confusing.  I do not recommend that you apply on your own.  The cost of long-term care can be extraordinarily high, costing up to $15,000 a month.  You should not leave your eligibility for this program to chance.  Worse still, applicants for benefits are often preyed upon by non-attorney Medicaid advisors whom the nursing home refer the applicant to because the advisory companies represent the interests of the nursing home, not the applicant.  Now, we have the county pushing applicants to provide difficult-to-obtain information in short order.  It’s a difficult process to navigate.