Appealing a MassHealth Denial Preserves Retroactive Nursing Home Coverage

In Massachusetts, Medicaid coverage of nursing home costs is obtained by filing a MassHealth long-term care application. Often, an initial denial is received, sometimes due to missing information. Not appealing that denial can have disastrous financial effects, so it is this office’s policy that every denial that is received during the MassHealth application process will be appealed.

Any MassHealth application can be retroactive to the first day of the third month prior to the application. Based on the date that MassHealth is needed, in many cases you must keep the original application alive. If an applicant receives a denial due to missing verifications and mails in missing verifications within thirty (30) days after the denial, that action is treated as a new application, causing a new application date, which affects the maximum time period that MassHealth can be retroactive.

For example, suppose Ezekiel applies for MassHealth on December 27, needing coverage as of September 20, when Medicare stopped paying. Under this application, MassHealth can be retroactive to as early as September 1. Only the original application, however, will obtain the needed retroactivity. If Ezekiel receives a denial on February 11 due to missing verifications and submits one or more of them during February, a new application is deemed to exist, and its maximum retroactive date would be November 1.

A later application date can also cause the date of payments of medical or nursing home bills to become important to whether retroactive MassHealth benefits will be allowed. The treatment of previously-paid expenses can be affected by the timing of the MassHealth application. Medical and nursing home expenses that are less than ninety (90) days in the past are allowed as part of the spenddown process whenever they are paid, but if those expenses precede the MassHealth application by more than ninety (90) days, then a different rule can apply. If we also suppose in the example in the previous paragraph that Ezekiel sold stock and received the proceeds on December 3 and immediately paid the nursing home at its private pay rate for the September 1-September 20 period, that action would have no impact on the effective retroactive date of MassHealth coverage for the original application. The result would be difficult if the denial of the original application were not appealed. Under a new application, that action could change the maximum retroactive date of the later application to December 3, the date the stock proceeds were paid to the nursing home.

There is a MassHealth regulation which allows a successful appeal of a denial to keep the original application alive. If Ezekiel had appealed the denial instead of just sending in the missing verifications, a new application would not be deemed to exist, and the original application would be preserved, thereby allowing MassHealth coverage to be retroactive to the earliest possible date.

When these procedures are not followed, the result can be that the nursing home will not be paid far enough retroactively by MassHealth, so the MassHealth applicant, his/her spouse or his/her payment guarantor will be responsible for the unpaid amount. (As a last resort, the only possible way to cover the shortfall could be to make a request to MassHealth that the unpaid nursing home bill be slowly paid over time via deductions from Ezekiel’s monthly income, but there would be no guarantee that MassHealth would help Ezekiel and the nursing home on the previously-disallowed nursing home bill.)