What is Medicaid Pending and How It Impacts Medicaid Long Term Care Benefits

Summary
Seniors who have submitted their Medicaid applications but are still waiting to be accepted or denied have “Medicaid Pending” status. This transitional period can be challenging since you or your loved one probably needs long term care but can’t afford it on your own. However, some nursing homes and caregivers will provide services to Medicaid Pending seniors knowing they will likely be paid by Medicaid in the future and not by the seniors themselves.

What Does “Medicaid Pending” Mean?

“Medicaid Pending” refers to someone who has applied for Medicaid but has not yet received an approval or denial. As mentioned above, there are some nursing homes and caregivers that will provide care to seniors who have Medicaid Pending status. These facilities and caregivers are expecting to be paid retroactively by Medicaid for the services they provided while the seniors were Medicaid Pending once those seniors are approved for Medicaid benefits.

Here are three more important facts to understand about Medicaid Pending:

• Seniors who resided and received care in a nursing home while Medicaid Pending do not need to reimburse the nursing home for any expenses if their Medicaid application is denied.
• Seniors who received care through Medicaid at home or in an assisted living home while Medicaid Pending might need to pay back those costs if their Medicaid application is denied.
• After a Medicaid application has been approved, nursing homes and caregivers will be reimbursed by Medicaid for all services they provided the Medicaid Pending senior from the date their application was filed to the date it was approved.

Medicaid Pending In Nursing Homes

Medicaid Pending is most often used for seniors who have Nursing Home Medicaid, which is sometimes called Institutional Medicaid.

As a quick recap: Nursing Home Medicaid will cover all the costs associated with living in a nursing home, including room and board, for anyone who meets the financial requirements and functional (medical) requirements. For more on Nursing Home Medicaid and its financial and functional requirements, click here.

One of the main differences between Nursing Home Medicaid and other types of Medicaid Long Term Care is that Nursing Home Medicaid recipients must give almost all of their income to the state to help cover the cost of nursing home care. They are only allowed to keep a small Personal Needs Allowance, which is usually around $75 / month, depending on the state.

As mentioned earlier, seniors who live in and receive care in a nursing home while Medicaid Pending do not need to reimburse the nursing home for room and board or any other expenses if their Medicaid application is denied. However, during their time living in the home, Medicaid Pending residents will be required to turn over their income, except for Personal Needs Allowance.

If a Medicaid Pending senior is approved for Nursing Home Medicaid while they are in the nursing home, Medicaid will reimburse the residence for the senior’s costs from the date their application was submitted.

Should Family Members Pay the Nursing Home Until Medicaid is Approved?

Please note that some nursing homes may ask the family of Medicaid Pending residents to cover the costs until their loved one is approved for Nursing Home Medicaid. We recommend family members do not make this financial commitment, because those costs will probably not get reimbursed, even if your loved one is approved for Medicaid. Until a Medicaid application is approved or denied, only the applicant’s income should be used to cover nursing home costs.

Finding a Medicaid Pending Nursing Home

It can be difficult to find a nursing home that accepts Medicaid Pending residents for the following reasons:

• The facility cannot be certain a resident will be approved for benefits.
• The facility is risking that it will not be reimbursed for services.
• Facilities have a limited number of beds for residents.
• Once an individual has been admitted into full-time nursing care, a nursing home is not allowed to discharge that resident for an inability to pay unless there is a safe alternative.

The best way to find a nursing home that accepts Medicaid Pending residents is to take the following steps:
1) Make a list of nearby nursing homes that may be of interest.
2) Call each home and ask if they accept Medicaid Pending residents.
3) Provide the home with a copy of one’s Medicaid application and any documents that prove the applicant is financially and functionally eligible and therefore likely to be approved for services.

Medicaid Pending for Home and Community Based Services Waivers

Home and Community Based Services (HCBS) Waivers are a Medicaid Long Term Care program intended to delay nursing home placement. To do that, HCBS Waivers provide long term care goods and services that will help beneficiaries who require a Nursing Facility Level of Care remain living “in the community” instead of moving to a nursing home. In all states, “in the community” means if the senior lives in their own home or the home of a loved one. And in some states, HCBS Waivers will also cover services for seniors who live in assisted living facilities, adult foster care or other group residential settings.

HCBS Waiver benefits can include:

• Case management
• Meal delivery
• Adult day care
• Respite care for primary caregiver
• Housekeeping assistance
• Home modifications for safety and accessibility
• Personal care help with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)

Depending on the state where they live, it’s possible for Medicaid Pending seniors to receive HCBS Waivers benefits. There is quite a bit of variance between HCBS Waivers rules in different states, so if you or your loved one is certain you application will be approved, you can contact providers and ask if they have special coverage options for Medicaid Pending clients. One’s local Area Agency on Aging may have a list of organizations that provide HCBS Waivers services through Medicaid Long Term Care. Click here to find the nearest AAA office.

Some HCBS Waivers have a limited number of enrollment spots, and once those spots are full, additional applicants are placed on a waiting list. Medicaid Pending seniors would most likely not be to receive benefits if they applied for one of these high-demand HCBS Waivers and ended up on a waiting list.

Medicaid Pending for Aged, Blind and Disabled Medicaid

Some HCBS Waivers have a limited number of enrollment spots, and once those spots are full, additional applicants are placed on a waiting list. Medicaid Pending seniors would most likely not be to receive benefits if they applied for one of these high-demand HCBS Waivers and ended up on a waiting list.Personal care services for older and frail adults are also available through states’ Aged, Blind and Disabled (ABD) Medicaid, also called Regular Medicaid. ABD Medicaid is an entitlement, which means all eligible applicants are guaranteed by law to receive benefits. That guarantee opens the door for Medicaid Pending seniors to receive ABD Medicaid benefits while they wait for their approval or denial. However, the Medicaid Pending senior must find a caregiver who is willing to provide benefits under these circumstances. The best way to do this is by contacting caregivers who accept Medicaid and asking their policy on Medicaid Pending clients.

These caregivers may ask to see a copy of your Medicaid application and financial statements. They would do this to determine for themselves how likely you are to be approved for ABD Medicaid and the long term care benefits you are asking them to provide. While there is no functional or medical requirement for general ABD Medicaid coverage, seniors must show a specific need to be approved for the corresponding specific specific long term care benefit. For example, you or your loved one would need to use a wheelchair to be approved for a home modification to add a wheelchair ramp.