What Happens If My Medicaid Nursing Home Application Is Denied, or I Do Not like the Patient Pay Amount as Determined?

medicaid denied

It is a big sigh of relief, after applying for Medicaid Nursing Home for yourself or a loved one, when the application has been approved. Normally, the process is long and multiple proofs are requested before the application is approved. And the application process, at times, can produce unfavorable results. Most unfavorable results are either a denial of benefits or too high of an amount that the benefit recipient must pay to the nursing home each month, also called the Patient Pay Amount.

So what can you do if the results are not what you had wanted? Every denial or determination of the Patient Pay Amount can be appealed. And just like with the application for Medicaid benefits, the appeal process starts with paperwork. A written request for a hearing must be submitted to DHHS. This written request must be filed within 90 days of either the denial or Patient Pay Amount determination. This, then, starts the administrative review process from DHHS.

The administrative review process gives DHHS time to review the Medicaid application, complete with all proofs that were sent. Typically, it is ideal to have the matter resolved at this stage with the assigned case worker, to avoid a formal administrative hearing. However, if an amicable conclusion is not reached, the matter will proceed to a formal administrative hearing.

The administrative hearing more closely resembles a court proceeding than an interview. There will be an administrative judge who will preside over the hearing, and evidence will be presented. Arguments will be made, and testimony will be taken. At the end of the hearing, the judge may state what their ruling is, or the judge may issue a written opinion that states their decision. The decision can be appealed to the circuit court, but there are specific allegations against DHHS that must be proven at this stage.

Regardless of your reason for wanting to appeal a DHHS determination, our office can assist you through the process after assessing your unique circumstances. Contact us today to set up a free consultation.


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