APPEALING DENIAL OR TERMINATION OF MEDICAID BENEFITS

© Copyright 2010 Lee A. Drizin, Chtd.

We represent individuals and facilities when access to long term care Medicaid benefits are at risk. It is critical to the success of your appeal that you timely request all available “administrative remedies.” Generally, administrative remedies consist of a “Hearing Preparation Meeting” or “conference” as it is usually called, and a “Fair Hearing.” The Notice of Decision will contain information on each remedy, but it is usually best to ask for both.

The purpose of a conference is to resolve the issue informally. The conference is held with a Hearing Representative, someone other than your caseworker, who reviews your file and can advise you of any options you may have. If a resolution is reached, you will not need to have a formal Fair Hearing, and your file is returned to your caseworker.

If the problem cannot be resolved at the conference, a Fair Hearing will be scheduled by the Hearing Officer. It is very important to attend this hearing, or immediately request rescheduling. Failing to do so will result in the action in your Notice of Decision to take effect. It is also important to consult with an experienced Elder Law attorney who can guide you through the process. Details that can determine the outcome usually involve:

  • The reason stated in your Notice of Decision
  • Knowledge of Nevada’s Medicaid manuals
  • Governing Federal and State law
  • Presenting your case to the Hearing Officer
  • Creating an accurate Fair Hearing record in case further appeal is necessary

After a Fair Hearing, the Hearing Officer will make a written Decision, which is sent to you or your representative. Decisions either affirm or reverse a Notice of Decision. In both cases, further appeal may be requested by the losing party. In addition, you may have the right to apply for an “Undue Hardship Waiver.” Undue Hardship Waivers may provide relief from a patient’s ineligibility.

What is an “Undue Hardship Waiver?”

In certain cases, even ineligible applicants can receive Medicaid benefits if an “undue hardship waiver” is granted. Put simply, a valid denial or termination of benefits can be avoided if it would produce an “undue hardship” on the applicant, his or her spouse, a disabled or “caretaker” child, or the facility in which the applicant is receiving care. If this application is successful, Medicaid “waives” the requirement that is not met, and the applicant is deemed eligible.

As you can see, the requirements for a successful waiver are not easily met, and the assistance of an experienced Elder Law attorney is recommended before requesting one. In addition, if the waiver is denied, a conference and Fair Hearing on this denial can also be requested, since it is a new issue. All appeal rights discussed above also apply to the denial of an Undue Hardship Waiver.

With our extensive knowledge and experience in handling these types of cases, we can assist applicants, or family members, in understanding and navigating this process. Retaining legal representation is often necessary to ensure that your rights are protected and facilities receive payment for a patient’s care.

Let our Elder Law Attorneys be your resource for accurate information and outstanding representation when you need it most. Whether your needs require a simple telephone call, or zealous advocacy, our services can help you and your family avoid costly mistakes and increase the likelihood of a successful application. At Lee A. Drizin, Chtd., our goal is to provide you with reliable support and solutions.

The information presented herein is general information only and should not be considered legal advice nor should you rely solely upon this information in taking any actions regarding your matter. While no attorney-client relationship is formed by supplying this information, please do not hesitate to contact us at (702) 798-4955 to schedule a time to discuss your particular circumstances.

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