Preventing a denial by Medicaid begins before a senior ever completes the Medicaid application. It is at this point that legal advice is critical to properly protect assets and qualify for Medicaid benefits. Even if no one thinks there will be a problem obtaining Medicaid benefits, it is best to have a lawyer review the senior’s assets, transfers, and expenditures for the past five years. Action can often be taken to correct things that would cause the senior to be denied benefits.
If the senior is denied Medicaid benefits; or, if the senior was granted Medicaid benefits but a later decision to deny future benefits is issued, the senior may appeal the decision.
To appeal, the senior must act quickly. The senior has 60 days from the date of the denial to file an appeal with the Alabama Medicaid Agency. If the appeal is not received within 60 days, for any reason, the senior will not be allowed to appeal.
For seniors who have been denied continued future benefits, the senior can prevent the loss of benefits during the appeal period by filing the appeal within 10 days of the date the decision was issued to deny further benefits. In other words, the senior’s benefits will continue until a decision on the appeal has been made. This may prevent a senior from losing valuable benefits (being discharged from the nursing home) over some sort of mistake that can be corrected during the appeal process.
The appeal must be written and filed with the Alabama Medicaid Agency. A phone call or visit stating that you disagree with the decision is not a method of filing an appeal. Ideally, the senior will obtain legal assistance with the appeal as the Alabama Medicaid Agency will have cited administrative regulations or laws in which it feels that the senior is noncompliant. While the senior may be very vocal about why benefits should be continued, if the precise administrative regulations or laws are not properly addressed, the senior will be unsuccessful on appeal.
After filing an appeal, the senior is entitled to a fair hearing. The senior has the choice of a hearing conducted by an administrative law judge; or, allowing the judge to rule based on the information provided to the judge. The administrative law judge’s ruling is then sent to the Commissioner of the Alabama Medicaid Agency. The Commissioner is then free to accept or reject the judge’s findings. Once the Commissioner has made a decision, if it is adverse to the senior, the senior has 15 days to ask the Commissioner to reconsider the decision. If this is unsuccessful and the senior has not yet retained an attorney, the senior should retain one because the senior has 30 days to file a notice of appeal in the circuit court of the county where the senior lives. At this point, there are very technical requirements for properly appealing the decision. The circuit court will hold a bench trial (a trial without a jury) to determine whether the administrative law judge and Commissioner ruled incorrectly and benefits should be given to the senior.
Editor’s Note: Melanie B. Bradford is an attorney located in Scottsboro, Alabama at 803 Garland Ferry Road at the intersection of Veterans Drive and Garland Ferry near The Daily Sentinel. Her phone number is 256-259-3301. The Alabama State Bar requires any communication that may be interpreted as an ad to state: “No representation is made about the quality of legal services to be performed is greater than the quality of legal services performed by other lawyers.”