I Need Help Applying for Medicaid Long-Term Care

Expect More Than One Eligibility Test

Medicaid long-term care can involve both:

• financial eligibility, such as income and assets
• care needs, such as whether the person meets the state’s required level of care

A person can need a great deal of help and still have financial eligibility questions to resolve.

A person can also meet the financial rules and still need a clinical or functional assessment before long-term care services are approved.

Ask:

“What financial and care-needs requirements have to be met, and who decides each one?”

Gather the Paperwork Early

The state may ask for records such as:

• identification
• Social Security and Medicare information
• proof of income
• bank and investment statements
• property information
• insurance policies
• trusts or annuities
• information about a spouse
• records of property or money that was sold, given away, or transferred
• medical information or a care-needs assessment

The exact list varies by state. Ask for a written checklist.

Say:

“Please tell me exactly what documents are still missing and where they need to go.”

Keep copies of everything you submit.

Don’t Move Money Just to Qualify

Long-term care Medicaid has rules about transfers of money and property.

For many applicants, the state reviews transfers made during the five years before the application. Giving away money, transferring a house, adding someone to property, or moving assets for less than fair value can delay eligibility for long-term care services.

That doesn’t mean every transfer causes a penalty. Exceptions and protections can apply.

Before gifting, retitling, transferring, or selling property to try to qualify, see I Need Legal Help →

Say:

“Before we move any money or property, I need to know how this would affect Medicaid eligibility.”

Be careful with anyone who charges to “get someone qualified” and isn’t a lawyer. Ask before you pay.

If the Person Has a Spouse

Don’t assume the spouse at home has to spend everything.

Federal Medicaid rules include protections meant to keep a spouse living at home from being left without income or resources when the other spouse needs long-term care. The amounts and calculations can change.

Ask the Medicaid agency:

“What income and resources can the spouse at home keep, and what documents do you need to calculate that?”

If the answer is unclear, or a large amount of money or property is involved, see I Need Legal Help →

Ask What Happens While the Application Is Pending

Ask:

• Has the application been received?
• Is anything missing?
• Has the care-needs assessment been completed?
• Is another agency or contractor involved?
• When should we expect a decision?
• What happens with the care bill while the application is pending?
• If the person is already in a facility, can they stay while Medicaid is being decided?

If someone tells you “Medicaid pending,” ask what that actually means in this case.

Say:

“What still has to happen before this application can be approved, and who owns the next step?”

If the Person Needs Care at Home

Ask specifically about home and community-based services.

Medicaid can cover long-term services outside a nursing home, but the programs, eligibility rules, services, and availability vary by state. Some programs may have enrollment limits or waiting lists.

Say:

“What Medicaid long-term care services are available at home, and is there a separate application or waiting list?”

If the person already has Medicaid, don’t assume home-care hours are automatically approved.

If the Person Needs a Nursing Home

Medicaid can cover nursing home care for people who meet both the financial and care-needs rules.

Ask the facility:

• Does this facility accept Medicaid?
• Does it accept Medicaid for long-term residents?
• Will it help with the application?
• What happens if Medicaid is denied or delayed?
• Is the person being admitted as Medicare skilled care, private pay, Medicaid pending, or something else?

If you’re still looking for a place that can meet the person’s needs, see I Need Help Finding a Care Facility →

If Medicaid Says No

Get the decision in writing.

Look for:

• what was denied
• why it was denied
• whether information was missing
• the appeal or fair-hearing deadline
• how to ask for review

Say:

“What exactly was denied, and what’s the deadline to challenge this decision?”

If the issue involves property ownership, transfers, trusts, a spouse’s resources, or another complicated financial rule, see I Need Legal Help →

Ask About Estate Recovery

Medicaid long-term care can affect the person’s estate later.

Federal law requires states to seek repayment from the estates of some people who received Medicaid long-term care at age 55 or older. There are protections and exceptions, including for surviving spouses and some children, and states must have a hardship waiver process.

Ask the state Medicaid agency:

“Which services here are subject to estate recovery, and what exceptions or hardship rules apply?”

Don’t wait until after the person dies to ask whether a house, a spouse, a disabled child, or another important asset may be affected.

Before You Rely on the Plan

Make sure you know:

• which Medicaid program the person is applying for
• where the application was filed
• whether it was received
• what documents are still missing
• whether the care-needs assessment is complete
• whether there’s a waiting list
• who’s following the application
• what happens with care costs while it’s pending
• what the appeal deadline is if it’s denied

“Medicaid pending” isn’t the same as Medicaid approved.