Your Medicaid Application Was Denied. Now What?

picture-for-lisa-medicaid-denialAs elder law attorneys, it is our goal to have each and every client’s Medicaid application to receive MassHealth benefits ultimately approved. However, the reality is that in some cases, an application may initially be denied.

Applications are denied for a variety of reasons. In the majority of cases, a caseworker denies an application because the agency received insufficient information to process the application. For example, a caseworker may need to review additional bank statements. Once the missing information (known as “verifications”) is submitted, the application can be resolved. Other applications are denied on legal grounds, such as when the agency deems an applicant’s irrevocable trust a “countable resource,” or when the agency determines that an applicant transferred assets in violation of the MassHealth rules and is disqualified from receiving benefits.

Once a denial is received, it must be appealed within thirty (30) days. If an applicant is already receiving benefits, the best approach is to appeal the denial within ten (10) days so that benefits are continued through the appeal process. An administrative hearing is then scheduled with the Office of Medicaid Board of Hearings. These administrative proceedings are called “fair hearings.”

During an administrative hearing, MassHealth is typically represented by a caseworker.   Also present is a hearing officer (who acts like an administrative judge), who presides over the hearing. The applicant for benefits and his or her attorney have the right to present evidence in favor of their case, as well as question any witnesses pertinent to the case. The hearings are recorded. It is common for the written record in the matter to be kept open for additional time following the hearing to allow for both parties to submit written memoranda in support of their positions. Submitting written memoranda is especially important if the application is denied for a legal reason, such as the transfer of assets into a trust.

If you lose your appeal before the Board of Hearings, you still have additional appeal rights. Following an adverse Board of Hearings decision, an applicant can request a rehearing directly with the Office of Medicaid. This request must be made within fourteen (14) calendar days from the date of the receipt of the hearing officer’s decision.  If that rehearing request is denied, the applicant has thirty (30) days to file a complaint for further judicial review in Superior Court.

A complaint for further judicial review of an administrative agency decision is typically referred to as a “30A appeal” by elder law practitioners in reference to the statute allowing such appeals. During a 30A appeal, the record the Court reviews is limited to the underlying administrative record. Thus, it is critical to submit as much information as possible during the initial administrative hearing process. Otherwise, you risk waiving valid legal arguments that were not originally addressed. In some limited circumstances, it may be possible to submit additional evidence during the 30A appeal.

During the judicial appeal, the administrative hearing officer’s decision receives deference by the reviewing court. The decision may only be overturned if the Court determines that it is arbitrary and capricious, an abuse of discretion, or otherwise not issued in accordance with the law. This is a high standard to meet, and it is for this reason that applicants for benefits and their attorneys are encouraged to treat the underlying administrative process as equivalent to a court proceeding.

If you are unsuccessful at the Superior Court, you still have the right to further appeal the decision at the Court of Appeals and, if necessary, to the Supreme Judicial Court. Such proceedings are very formal and require preparation in accordance with the Massachusetts Rules of Appellate Procedure. However, in some instances, such as in the case of an irrevocable trust or special needs trust denial, the proper interpretation of the Medicaid statute to the applicant’s case may best be served by the review and decision of a panel of skilled appellate justices that make up these two courts.

The Medicaid appeal process is complex, and all deadlines must be complied with to ensure the continuance of the original application date and benefits, if possible. It is best to seek the advice of a qualified attorney experienced in handling such applications at the outset to avoid a costly error and to increase the likelihood of acceptance of the original application or the success of any appeal.

About Lisa Neeley

Lisa is an attorney in the Firm's Trusts and Estates Group. She focuses her practice on elder law, estate, and special needs planning matters.   Lisa assists clients in the preparation and filing of complex MassHealth applications, from the planning and filing process through representation for any necessary appeals. In conjunction with her MassHealth expertise, Lisa has represented clients in appeal hearings regarding benefit eligibility issues before the Board of Hearings, Superior Court, and Massachusetts Appeals Court. In addition, Lisa has expertise in assisting elderly and disabled clients with the process of applying for community MassHealth benefits to enable them to remain in their homes while receiving care.    Lisa routinely assists clients of all ages with the preparation of estate and long-term care planning documents, including powers of attorney, health care proxies, wills, and trusts. She regularly appears in Probate Court to represent individuals and families in guardianship, conservatorship, and estate administration matters. Lisa frequently speaks to local senior centers, hospitals, nursing homes, and community groups on estate and long-term care planning topics. She is an active member of the Massachusetts Chapter of the National Academy of Elder Law Attorneys (NAELA). In 2016, Lisa was a recipient of the John Ford litigation advocacy award by the National Academy of Elder Law Attorneys (NAELA) in recognition of her dedication and commitment to people as they age and for people with special needs.
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