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.

If the senior is approved, Medicaid will pay for all care received going back to date of the application. If the senior is denied, Medicaid will not pay and the facility or caregiver will attempt to collect payments from the senior and/or their family.

An applicant’s Medicaid Pending status lasts until they are either approved or denied coverage, and that includes time for a fair hearing to appeal a denial. States are required to respond to Medicaid applications within 45 days, or 90 days if the application requires a disability determination. However, states can file for an extension and it takes most of them close to three months to respond to all applications. It can take more months to schedule an appeal hearing if the applicant believes they were wrongly denied.

 

Medicaid Pending In Nursing Homes

Medicaid Pending is most often used for seniors who have Nursing Home Medicaid, which is sometimes called Institutional Medicaid. It will cover all the costs associated with living in a nursing home, including room and board, for anyone who meets the financial and functional (medical) requirements.

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. This also applies to Medicaid Pending seniors who are living in a nursing home, except they give their income directly to the nursing home. In both cases, the nursing home resident is allowed to keep a small Personal Needs Allowance, which can range from $30/month to $200/month, depending on the state. They can also keep enough to make Medicare premium payments if they are dual eligible, and enough to make any Monthly Maintenance Needs Allowance payments to eligible spouses. But they must give the rest of their income to state or the nursing home to help cover the cost of care.

 

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

While Medicaid Pending seniors are required to give most of their income to the nursing home, they are not required to make any other payments. However, some nursing home administrators may still ask seniors or their families to cover bills, but they should not pay. The payments could actually make the Medicaid applicant ineligible. Even if they don’t, Medicaid is not likely to reimburse the senior or their family for making them.

Even if a Medicaid Pending senior or their family feels pressure to make payments, they should know nursing homes are not allowed to evict Medicaid Pending residents. If the Medicaid application is eventually denied, the nursing home can evict the senior if they can not pay their bills, but the facility has to provide a plan for the senior’s care and residence before evicting. The facility will also attempt to collect the unpaid bills.

 

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 waitlist.

 

Medicaid Pending for Aged, Blind and Disabled Medicaid

Aged, Blind and Disabled (ABD) Medicaid can also cover long-term care services and supports in the community, and Medicaid Pending seniors may be able to access some of these ABD Medicaid long-term care benefits, depending on the state.

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, the medical requirement for long-term care benefits through ABD Medicaid is showing a need for that 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.