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MassHealth Applications and Appeals:

What to Do if Your Application is Denied

In Attorney Barreira’s opinion, all MassHealth denials should be appealed, even if the MassHealth eligibility worker seems to be working on resolving the problem.  The appeal can always be withdrawn later, once the problem has been officially resolved, and written proof of the resolution has been received. 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.

Whenever a MassHealth applicant receives a denial, it can be appealed through a process known as a “fair hearing.”   Preparation for a fair hearing needs to be thorough.  It is the only opportunity for the appellant to present factual evidence.  Attorney Barreira is experienced and knowledgeable and can help you through what can be an extremely complicated process.

There are three basic types of MassHealth denials.  One common denial is for “disqualifying transfers,” which includes gifts, below-market sales, or unexplained cash withdrawals within the five years prior to the application.  The timing of the MassHealth application can affect whether disqualifying transfers will be an issue.

Another common denial is for “excess assets,” which can mean the applicant would need to “spend down” the excess assets before the application would be approved.  A spouse can spend down the assets by purchasing a certain type of annuity or can simply refuse to spend down the excess assets.

Often, when MassHealth sees a trust, it argues that the assets in the trust are countable and need to be spent down.  Until recently, that type of denial was frustrating because the MassHealth agency would not disclose what was wrong with the trust until the fair hearing had begun.  A lawsuit filed by Attorney Barreira in 2019 resulted in the Suffolk Superior Court entering a declaratory judgment that MassHealth applicants have a right to know all the reasons their applications have been denied, making trust appeals much easier to prepare for.  (See IrrevocableTrust.info for examples of fair hearings decisions involving trusts.)

The most common denial is for what is known as “missing verifications.”  Resolving the issue of missing verifications can be relatively simple but the timing is important, and the denial needs to 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 instead of appealing, 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 September 27, needing coverage as of June 20, when Medicare stopped paying. Under this application, MassHealth can be retroactive to as early as June 1. Only the original application, however, will obtain the needed retroactivity. If Ezekiel receives a denial on December 11 due to missing verifications and submits one or more of them during December, a new application is deemed to exist, and its maximum retroactive date would be September 1.

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.

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 September 3 and immediately paid the nursing home at its private pay rate for the June 1-June 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 September 3, the date the stock proceeds were paid to the nursing home.

When these appeal procedures are not followed correctly, 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 overtime 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.)

For more information on Fair Hearings, see What Is a Fair Hearing under MassHealth, and Can You Really Expect It to Be Fair?

Additionally, Attorney Barreira continues to collect fair hearing decisions and memoranda submitted at fair hearings by the lawyers representing the Office of Medicaid and publishes them online at IrrevocableTrust.info. For some issues in non-trust cases, he maintains fair hearings at MassHealthAppeals.com.

 

For advice on MassHealth Applications and Appeals, please use the Contact Form below or call the office of Brian E. Barreira at 508-747-8282 to schedule a personal appointment and, if travel is a problem for you, he can conduct a Zoom meeting with you.