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The Four Phases of Medicaid Eligibility

Medical Supplies

Talking about Medicaid with elder care professionals can be very confusing.  They talk about things like looks backs and spend down when all you are worried about is making sure you loved one’s care is paid for when they run out of money.

Medicaid is so confusing that it’s hard to know where your loved one is in the process.  People say things like Medicaid eligibility but what does that mean? What about terms like Medicaid pending or Medicaid approved?  This article is going to look at how people talk about the Medicaid application process and explain the different phases of Medicaid Eligibility.

Phase 1 – Your loved one isn’t eligible for Medicaid.  In this phase your loved one doesn’t qualify for Medicaid.  She might have too much money or not enough medical needs or both.  Something has to happen before she will be eligible for Medicaid benefits.  She has to spend her money under the Medicaid qualifying limit or her health or cognition needs to decline to the point where she needs help with her activities of daily living to be medically eligible.

Phase 2 – Medicaid Eligible – It has been determined by someone other than the Medicaid office that your loved one is eligible for Medicaid benefits (but that doesn’t mean she gets any benefits – yet).  Once your loved one has met the Medicaid eligibility requirements – both financially and medically – she is eligible for Medicaid benefits. However, before Medicaid will begin paying for her care her case must be reviewed by the Medicaid office at the County Board of Social Services.  She will become eligible for Medicaid benefits once they approve her application for benefits.

Phase 3 – Medicaid Pending – Your loved one is Medicaid pending when she is eligible for Medicaid benefits and you have started the Medicaid application process but her application hasn’t been approved yet.  We say the Medicaid pending phase begins as soon as you have made an appointment to submit your Medicaid application – you have a date when you are going to meet with the Medicaid caseworker and formally apply for benefits.  From that point up until you receive a letter approving your loved one’s Medicaid benefits you are Medicaid pending. Just because you have applied for benefits doesn’t mean your loved one will get them. Medicaid is going to look closely at how your loved one’s money was spent during the five years before she became Medicaid eligible.  If you don’t give Medicaid what they need to review how the money was spent during that time period they will probably deny her application for benefits. If they determine she gave money away during that time period they will probably assess Medicaid penalties.

Phase 4 – Medicaid Approved – After Medicaid completes their review of your loved one’s application for benefits they will either approve or deny the application.  If they approve the application then your loved one will begin to receive Medicaid benefits to pay for the cost of her long term care. If they deny the application you will have to appeal their decision or start over.  Just because Medicaid approves the application doesn’t mean everything’s okay. Your loved one may have been assessed Medicaid penalties as a result of how they used their money before applying for Medicaid. However, in most cases, Medicaid approval is the final stop in the Medicaid application process and they will begin paying for benefits immediately following approval.

Watch Out  – Medicaid is a very complicated process.  If your loved one needs Medicaid benefits or may need them at some point in the future you should speak to an elder law attorney experienced in the Medicaid application process.  A lot can go wrong when applying for Medicaid benefits and working with an elder law attorney can help identify and, hopefully, prevent problems from occurring (or at least minimize the impact of the problems if they do happen).

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