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

When someone is “Medicaid Pending,” it means they are in the transitional phase between applying for Medicaid and being accepted into the program. Someone who has applied for Medicaid and is waiting to receive an acceptance or denial, in other words, is considered Medicaid Pending, and this is an important classification for the purposes of receiving care. Someone who is Medicaid pending can still have their long term care costs covered, including the price of living in a nursing home, but different rules apply.


What Does “Medicaid Pending” Mean?

Someone who is Medicaid pending has applied for Medicaid benefits and has not yet received an approval or denial of services. These are some of the basic, important facts relevant to someone who is Medicaid pending and needs help paying for long term care services including nursing home care:

– There are nursing homes, assisted living communities, and even some in-home care providers who will provide care to clients during the Medicaid-pending period.
– Someone who lives in a nursing home while Medicaid pending does not need to reimburse the nursing home for care fees or rent if their Medicaid benefits are denied.
– Someone who receives care services through Medicaid, at home or in an assisted living home, might need to pay back those costs if their Medicaid benefits are denied.
– Nursing Home Medicaid covers all costs of living in a nursing home, whereas Medicaid will cover care costs but not room and board for someone in assisted living.
– After a Medicaid approval, nursing homes and care providers to someone who is Medicaid pending will be paid back by the program for services provided from the date the application was filed.

 How Long for Medicaid Approval? The law says Medicaid must approve or deny an application within 90 days. However, for a variety of different reasons, it is very common for Medicaid approvals and denials to take considerably longer.


Medicaid Pending In Nursing Homes

Medicaid pending status is most often relevant for recipients of Nursing Home Medicaid, which is also 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 limits and is assessed as functionally needy. For more on these qualifications, click here.

The difference between Nursing Home Medicaid and the other types of Medicaid Long Term Care described below is that recipients of Nursing Medicaid must turn over all their income, minus a small personal needs allowance, in order to receive this benefit.

If someone applies for Nursing Home Medicaid and then moves into a nursing home that accepts Medicaid pending clients, they will not need to reimburse the home for care costs if their application is denied. However, during their time living in the home, Medicaid-pending residents will be required to turn over their income, except the small personal needs allowance. In other words: Someone who receives Nursing Home Medicaid must pay almost all of their income to Medicaid in order to receive benefits, but while they are Medicaid pending the income goes to the nursing home instead. Once the benefits are approved, a recipient’s income goes to Medicaid and Medicaid pays the nursing home.

 A Medicaid applicant who is married has the option in many states to transfer some or all income to the spouse as a “monthly maintenance needs allowance.” Click here for more info.

If the Medicaid-pending applicant is approved for nursing home coverage: Medicaid will reimburse the nursing home for costs while the resident was Medicaid pending (so beginning from the date the application was submitted).

If the Medicaid-pending applicant is denied for nursing home coverage: The nursing home will attempt to collect past-due bills from the resident and/or the resident’s family.


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

Please note that some nursing homes may ask for the new resident’s family to cover costs while the resident is Medicaid pending. It is not a good idea for family members to pay a nursing home during the Medicaid-pending period, as those costs will probably not be reimbursed if Medicaid approves services. Until a Medicaid application is approved or denied, only that 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 these reasons:
– The home cannot be certain a resident will be approved for benefits.
– The home is risking that it will not be reimbursed for services.
– Homes 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 waivers are a Medicaid Long Term Care program that helps older or frail adults receive personal care in their own homes or assisted living communities. HCBS waivers are usually for Medicaid-eligible people who need a nursing facility level or care, meaning they would be eligible to live in a nursing home but can remain in their own homes with services provided through Medicaid. Because nursing homes are expensive, this saves the program money.

Among the benefits provided through HCBS waivers are the following:
– Home modifications
– In-home help with activities of daily living, like eating and bathing
– Meal delivery
– Respite care
– Physical therapy

Can someone who is Medicaid pending receive HCBS waivers? It is possible, depending on the state. There is quite a bit of variance between Medicaid waiver rules in different states, so if someone is certain their application will be approved, it’s a good idea to contact providers and ask if they have special coverage options for people who need in-home care and have applied for Medicaid but are not yet approved. One’s local Area Agency on Aging can provide a list of organizations that provide waiver services through Medicaid Long Term Care. Click here to find the nearest AAA office.

It is possible there may be a waiting list for HCBS waivers, as they are not considered an entitlement and often only have a certain number of slots available. In that case, it is very unlikely that someone who is waiting for Medicaid approval would be able to receive HCBS waiver benefits.


Medicaid Pending for Aged, Blind and Disabled Medicaid

Personal care services for older and frail adults are also available through states’ Aged, Blind and Disabled Medicaid, also called Regular Medicaid. ABD Medicaid is like Nursing Home Medicaid (and unlike HCBS waivers) in that it is considered an entitlement, meaning anyone who meets the eligibility criteria must be accepted for benefits.

Because ABD Medicaid is considered an entitlement, it may be possible to receive benefits while still waiting for an acceptance or denial from state Medicaid offices. It depends on the care provider.

ABD benefits are usually not as comprehensive as those provided by HCBS waivers, but it still may be possible to receive ABD benefits while one is Medicaid pending. The way to do this is by contacting care providers who accept Medicaid, and asking whether they can help Medicaid-pending clients. They may charge out-of-pocket until the Medicaid benefits are approved, in which case Medicaid might reimburse those costs via retroactive eligibility.

One is advised to be prepared to show the Medicaid application and any documentation that shows an approval is likely, meaning proof that one’s income and assets are below the state’s limits. ABD Medicaid, unlike other Medicaid Long Term Care programs, does not have a functional or physical eligibility requirement.