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5 Top Reasons Medicaid Benefits Are Denied to Seniors

5 Top Reasons Medicaid Benefits Are Denied to Seniors

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Many senior adults depend on Medicaid benefits as part of their health coverage, so when benefits are denied it can create serious problems for them. This article will discuss the 5 most common reasons Medicaid benefits are denied to seniors and what you can do if you are faced with Medicaid denial.

What is Medicaid?

Not to be confused with Medicare, Medicaid is a federal and state program that provides health coverage benefits to many groups of individuals, including:

  • Low-income adults
  • Children
  • Pregnant women
  • People with disabilities
  • Senior Citizens

While the program is administered on the state level, it’s done so per federal requirements.

As of November 2019, there were 64,498,259 individuals enrolled in Medicaid. That alone should give you a clear idea of how popular the Medicaid system has become.

Medicaid Denial

5 Top Reasons Seniors Are Denied Medicaid Benefits

You have every reason to believe you’re eligible for Medicaid, and then something happens: you receive a denial letter.

This can happen, especially when you don’t understand the Medicaid program in your state, including its eligibility requirements. 

Some of the most common reasons for a Medicaid denial include:

1. You Submitted an Incomplete Application

On the plus side, this is an error you can fix. You can submit the necessary information to have your application reviewed again. However, an incomplete application will slow down the process, so it’s a good idea to do everything right the first time around. 

2. You Have Excessive Resources

Not everyone qualifies for Medicaid, and tens of millions of people only have access because of their income level. You need to understand countable resources, by Medicaid standards, so that you don’t make a mistake that disqualifies you from benefits. For example, if you receive a large inheritance, it could disqualify you from receiving Medicaid in the future. 

3. Medicaid Penalty Periods

For instance, you may find that you have too many financial resources to qualify for Medicaid. So, you get the idea to transfer your assets to someone else, such as a child or other relative. To protect against this, there’s a Medicaid look-back period. The look-back period is 60 months in every state, with California the only exception at 30 months. This is designed to stop people from giving away assets to qualify for Medicaid. 

4. Not Medically Qualified

Your income may not qualify you for Medicaid, but you may assume that a medical condition will. Generally speaking, you must be blind or disabled to obtain Medicaid benefits on a medically needed basis. Proving this, particularly a disability, is often more difficult than it sounds. 

5. A Casework Mistake Was Made

When you file for Medicaid, a caseworker takes over your application to decide in favor of or against approval. Caseworkers are mostly qualified, experienced, and knowledgeable, but that doesn’t mean they never make mistakes. 

Tip: you have the right to hire a Medicaid attorney to assist you with every step of the process. They can review your situation, assist with the application, and take steps to help you obtain eligibility. And in the event of a denial, they can step in to help with the appeal process.

What Are The Most Important Medicaid Benefits?

With the help of broad federal guidelines, each state has the power to administer their own Medicaid program. It’s the decisions made on the state level that dictate Medicaid benefits including the scope of services, type, amount, and duration of coverage available to members.

However, it’s important to note that federal law requires every state to provide a certain level of Medicaid benefits to residents who qualify. These benefits include (courtesy of the Medicaid website):

  • Inpatient hospital services
  • Outpatient hospital services
  • EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
  • Nursing Facility Services
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Nurse Midwife services
  • Certified Pediatric and Family Nurse Practitioner services
  • Freestanding Birth Center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women
  • Individual states can offer optional benefits, including but not limited to:
  • Prescription drugs
  • Occupational therapy
  • Physical therapy
  • Clinic services
  • Dental services
  • Optometry services
  • Chiropractic services
  • Podiatry services
  • Personal care
  • Hospice
  • Upon enrolling in Medicaid, you’ll receive additional information on covered services.

Medicaid Eligibility Requirements

Unlike Medicare, which everyone qualifies for upon reaching age 65, Medicaid has strict eligibility requirements.

Here are the primary points of consideration:

Financial Eligibility

Upon the passing of the Affordable Care Act, a new methodology for determining income eligibility for Medicaid was implemented.

Through the use of your Modified Adjusted Gross Income (MAGI), the new set of standards makes it easier to understand eligibility and to apply and receive benefits.

The Medicaid income limit is based on a percentage of the federal poverty levels, which is outlined in this chart for the 48 contiguous states and the District of Columbia.

2020 Poverty Guidelines For the 48 Contiguous States and the District of Columbia
For families, households with more than 8 persons, add $4,480 for each additional person
Persons in Family/Houshold Poverty Guideline
1$12,760
2$17,240
3$21,720
4$26,200
5$30,680
6$35,160
7$39,640
8$44,120

In some cases, individuals are exempt from MAGI-based income counting rules, such as those who are age 65 or older, disabled, or blind.

Non-Financial Eligibility

While your financial situation is a determining factor, there are other non-financial eligibility requirements to obtain Medicaid benefits.

For example, you must reside in the state in which you’re receiving Medicaid benefits. Also, you need to be a citizen of the United States or part of a qualified non-citizen group, such as a lawful permanent resident.

Medically Needy

As noted above, many people qualify for Medicaid because of a disability.
Every state has the option to implement a medically needy program, designed for those who have extensive health care needs but don’t qualify for Medicaid because of their income.

As a member of this group, you can spend down the amount of income above your state’s medically needy standard, such as through expenses that are not covered by your health insurance.

The Centers for Medicare & Medicaid Services website makes special note of 209(b) states:

209(b) states also must allow a spend-down to the income eligibility levels eligibility groups based on blindness, disability, or age (65 and older), even if the state also has a medically needy program. Thirty-six states and the District of Columbia use spend-down programs, either as medically needy programs or as 209(b) states.

Medicaid Benefits: Frequently Asked Questions

It doesn’t matter if you’re learning more about Medicaid, in the process of applying, or already have access to this government program, you’re likely to have questions.

While the answers often differ from state to state and person to person, it’s essential to understand your particular situation. Here are some of the most frequently asked questions:

What’s the best way to apply for Medicaid?

You have several options, including through the Health Insurance Marketplace or directly with your state’s Medicaid office.

Each state has its own process, so make sure you collect information for the state in which you reside.

Do all Medical Providers Accept Medicaid?

No. You’ll want to verify that a provider accepts coverage before receiving care. You can obtain a list of providers by contacting your state’s agency.

How do I know if I am eligible for Medicaid?

Since every state has different requirements, you’ll want to consult with your state’s agency to learn more about your eligibility.

If you’re wondering if you qualify based on income alone, the Healthcare.gov website has a simple tool you can use.

Final Thoughts on Medicaid Benefits and Denials

As a federal and state program, there is a lot of gray area regarding the Medicaid system, so it’s vital to learn more about the basics and how they pertain to your personal circumstances.

Now that you understand where to start, you can decide if you’re currently in a position to apply for benefits. Even if you’re not eligible right now, you may be able to receive Medicaid benefits in the future. After all, there are more than 64 million people who are currently taking advantage of the program.

Note: Visit this page of the official Centers for Medicare & Medicaid Services website for state-specific Medicaid information.

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