Was Medicaid falsely terminated? Should we appeal this decision?

I truly feel your pain. I've been dealing with my Mother's care. She private paid for nursing home till all her money was gone, then finally I applied for Medicaid and she was approved without too much of a hassle at all. Then about a month or so ago I found out we have to reapply every year.
Well I let her checking account go over the minimum $2K by accident and it's been hell every since. I reapplied per Nursing Home Office Mgr.,
then they wanted more into, I sent that. Nursing home office told me to private pay for month of September to show we are doing our part in the meantime, I did.

They denied her application, I was then told I had to submit about 2-3 years of bank statements, which was a royal pain in the behind and to submit receipts for any transactions over $200! OMG!

I submitted all the bank statements, but not the receipts at the time, cause I don't even think I have all the receipts anymore. She was denied AGAIN. She is 90 years old! We cannot afford the nursing home bill nor are we qualified or able to bring her home.

I, like you, am at my witts end. I don't know what to do anymore. If I reapply it will probably be denied again. And it IS very hard to get
definitive answers from those that should be able to help me. I don't understand why they are now looking back at everything when she was originally approved 1 year ago!

I'm just praying she won't be put out on the curb. She is such a sweet and loving lady. Feel free to email me anytime.

Ok, here is the explanation. Medicare Savings Programs (MSP) are based on being within certain resource and income limits. Qualified Medicare Beneficiary (QMB) is for the lowest income, and the next level is SLIMB. That will have the state pay his Medicare premium and he gets his full SSDI check. (By the way, if the money from Social Security comes on the first it is SSI and if the disability check comes another day it is SSDI.)
Next step is to decide how you want to cover what Medicare doesn't cover. This is where Medicare Supplement or Medicare Advantage plans that you buy in the public market place comes in. Or you may get help from charities that help with costs for people with certain types of illnesses. And here is where additional aid from the state Medicaid program comes in. So whatever the program is called in your state, you have a cost sharing responsibility which might be called cost sharing or spend down or something else. This means that if qualified based on resources you will have a certain amount you have to pay...or at least owe...in a 3 or 6 month period before the state picks up the rest for you. Example: income of 1220 per month, less 20 (it's just the rule) = 1200 -735 (which is the max in 2017 that a person on SSI gets...it's just the rule) = 465 per month available for medical expenses. Muliply 465 x 6 months =2610 which is your share of your mefical costs. Submit the bills to the state within 30 days of the end of the 6 months and the state will pay the amount over your share of 2610. You renew your eligibility for this every 3-6 months. You decide which is better for you, paying for your Advantage or Supplemental plan, spend down or both. Hopes this helps. I work with eligibility for this program on a daily basis. My state has whole units of people whose job it is to look at people's medical bills when they have qualified for spend down and pay those bills. Oh, and other news...you can ask for three months retroactive coverage when you first apply. So say you were hospitalized in last three months and only had Medicare because you hadn't done anything to cover what Medicare doesn't pay. Now you have a huge bill. Apply for state assistance and if you are considered financially needy part of that retro period bill may also be covered. Just don't delay. Hope this helps.

JASR16, definitely see a lawyer. If the 401K which is considered an asset for Medicaid qualification is above $2000, that is probably part of the disqualification for Medicaid. Medicare and Disability have asset limits for Medicaid benefits qualification. It's such a maze. However, since it's for medical expenses, you may be able to argue your way out of an early withdrawal penalty for tax purposes with state and federal authorities while setting up a way to help your father. A good disability lawyer will have some referrals for that part of financial planning.

I spent a good portion of my night in tears because of how stressful this is for us. Like I said I am grateful that he has some sort of coverage but what happens when he cannot afford to cover the 20% that is left over? It is easy for Medicaid reps to say, “well I’m sorry I wish there was more I could do” when they aren’t the ones in this situation. It is crazy to think that there are so many people milking the system receiving benifits that they should not and the people who genuinely need them to stay alive have to go without! Confusing indeed Shane, I find it so hard to grasp that Medicaid is an income based program, my dad fits the criteria of being “financially needy” being that his SS disability check is definitely under that income limit here in NM but “does not qualify” what is the point of dual eligibility then? I KNOW there are people out there who are receiving both so what’s so different about him! We are definitely going to be looking into a disability lawyer, as I do not believe that there’s nothing else that can be done. We were told that since he is receiving Medicare and Disabilty he cannot receive full Medicaid. That it “just doesn’t work that way” ugh.

In regards to 401k, he does have some put away from his previous job but nothing big what so ever. Maybe a couple of months worth and the last we were told was that it is not worth trying to use because more will be taxed than given back to him.

That is terrible, Jasr, that Medicaid will be stopped. Also terrible is how difficult it is to get straight answers re Medicare & Medicaid.

So, now he will need a secondary policy to pay the 20% Medicare won’t covef for dialysis.

Many states have separate programs for ESRD patients to assist them in getting a secondary. For instance in Maryland we have Maryland Kidney Fund that can assist with paying secondary insurance premiums. Again your dad’s dialysis social worker should be able to help with getting your dad enrolled in a secondary policy & maybe even paying the premiums for him.

Now that you have taken your precious time to get a definitive answer, go back to the MSW @ dialysis & inform her of what you just learned.
She/he should assist in finding him a secondary policy due to his special status as ESRD.

Usually if an ESRD patient has their own insurance through their employer or through ACA, the patient’s insurance continues to be their primary & Medicare their secondary for a period of time, last I knew it was for 36 month “coordination” period as Medicare delays paying the 80% as long as they can and bill the commercial primary. 

That’s why I don’t understand why Medicaid was denied at all.

Confusing? Absolutely.

I am sorry the both of you are going through this. Are you certain that your father doesn’t have an old 401k somewhere from a prior job? Something you all don’t know about or maybe dad forgot about it?

I can’t figure this one out either.

Jasr, find a disability lawyer versed in Medicaid. I found the following description of Medical programs in New Mexico and I THINK I've found the reason for disallowance. Page 5 describes one of the Medicaid Categories your father's in.
**Supplemental Security Income (SSI)
Categories 001, 003, and 004 – The Social Security Administration determines eligibility for
these categories. SSI provides cash benefits and Medicaid provides health care coverage for
eligible individuals under aged (Category 001), blind (Category 003), or disabled (Category 004).
The maximum monthly income benefits provided under this program are $735 for an individual
and $1,103 for a couple. If the applicant is a minor child, a certain portion of the parents’ income
is considered available to the child. Resource limits are $2,000 for an individual and $3,000 for a
couple. A burial fund of up to $1,500 is excludable.**
www.hsd.state.nm.us
New Mexico DOES HAVE Qualified Income Trusts. Your father may qualify for one of these programs where the money from disability goes into a Trust above the qualifying amount. You may find a low cost or pro bono attorney that does it; it could be well worth more to get state benefits that your father makes too much money to qualify for at $1220.

Well everyone just left Medicaid office and was informed that there is nothing that can be done. They stated that because he is receiving Medicare and SSDI he does not qualify for full Medicaid. There may be programs to help cover some services such as transportation, prescriptions, etc. but we would have to contact Medicare for all of that! Not sure what to think but I guess we should be grateful that he has the Medicare to cover his treatments and such. *sigh*

Thanks you all! It’s been a long day but after a nice long needed shower I decided that it’s best to remain calm instead of freaking out and panicking. This situation is beyond stressful, especually because my father is so young and going through so much but freaking out isn’t going to make anything better. I will come back on tomorrow and let you all know how things went in person. Please send good vibes!!

Definitely go in person to talk to Medicaid worker, taking all the documentation you can so that the situation is clear to them. You should certainly be entitled to know what is the basis of their decision and also what alternatives they can suggest. They can be incredibly helpful, but in-person is better than phone.

My mom got a pooled trust to qualify for Medicaid, under similar circumstance, her income being a little too high otherwise but way too low to actually cover her care. My experience is that most people don't know about this pooled trust option-- I found out about it from the Alzheimer's Association. (My mom has memory loss, which is called dementia in medical diagnosis language.) She pays her Medicaid spend down to the trust, and her rent is paid from that, that is how it works.

Your local council on aging may be able to help you investigate a trust -- in my state, NY, we needed a pro bono lawyer to set it up.

Have you asked if he qualifies for the QMB program? That would cover Medicare parts AB premiums and out of pocket. It may be that he’s not qualified for one program and its specific requirements but does qualify for the other. Qualified Medicare beneficiary program.

Hello guestshopadmin! I don’t think Medicare premiums are being taken out of the $1220 because from what we were told he was enrolled into Extra Care program and SLIMB that helps pay those premiums because he is low income?.. BUT not too sure if that is also going to be terminated with Medicaid on nov. 1 now that I think of it! We are in a very confusing situation. Being that he is enrolled into those programs the $1220 would put him under income limit making him eligible for Medicaid am I right? I hope I am not coming off as ungrateful or unappreciative for the benifits he is still receiving because I know there are people who have no coverage at all. I just don’t understand why his Medicaid is being terminated. Like I stated above NO ONE I have spoken with on the phone has been helpful. We did go ahead and reapply for Medicaid Benifits online and will be headed to Medicaid office first thing tomorrow morning to speak with someone face to face. I was under impression that he’d be eligible for dual eligibility but I guess I was completely wrong.

*I’d like to add that I just went back and checked his benifits report and it states that $1220 is before deductions if any apply. Which they don’t because of SLIMB.

Is the $1220 net after Medicare premium? The monthly income limit in New Mexico is $1316.67 or $15,800 per year for household of 1. The federal Medicare premium is usually between $109 and $134 per month. It’s possible his income if Medicare premium is high enough that he is above Medicaid limit. If that is case you might be able to set up a QIT qualified income trust in New Mexico where the excess money goes into trust, brings your income below Medicaid level, and voila! Look at the gross income on Dad’s stub for disability to see if it exceeds the monthly amounts. If no one will help you, find a Medicaid and disability lawyer that can. Still cheaper than all healthcare out of pocket.

Hi Jeanne and Shane! Thanks for the input. Yes he does have a social worker at dialysis who “should” be on top of this but sadly we have tried many times to consult with her and inform her of our issues and she isn’t much help. She always tells us to call Medicaid office or take paperwork in and have them try to resubmit! I have spent about 5 hours today making numerous phone calls, I’ve tried Income support, human services dept, SS department, his MOLINA healthcare case worker.. NOBODY has been helpful to us!! We were told that there is nothing more that can be done, that he does not qualify for dual eligibility, he has Medicare so he no longer qualifies for Medicaid, his income is too high for Medicaid, that if there are any Medicaid programs he qualifies for that they will only be partial and may only cover Medicare premiums, that he will no longer qualify for full Medicaid because of his Medicare and income... which is complete bull because I know there are people with dual coverage in his exact position! Ugh! I don’t know what else my brain feels so stuck. The last person I was able to speak with suggested reapplying for Medicaid online or going into Medicaid office and speaking to someone in person so I had him apply online once more and we will be going in person tomorrow as well. I feel so trapped and helpless. My father is only 43 and going through so much. Yes only 43! I do NOT understand how they are trying to tell me that his income is too high, he will be making $1220 in disability ONCE a month and from my understanding federal poverty level for 1 is around $1300 in New Mexico. So he is below and should qualify am I right? Does anyone know what the exact poverty guidelines in NM are?

Well, it sure sounds like an error to me. By all means, appeal the decision. There should be instructions for appeal in the letter that informed you of the termination. The case worker may be overwhelmed (especially if a lot of erroneous terminations went out), but a formal appeal must be reviewed promptly. Do that.

Talking to the social worker at dialysis as Shane suggests is also a wonderful idea. Maybe he or she can help you with the appeal.

Come back and let us know how this works out. We care!

Your father has a social worker at dialysis. I suggest asking her as this is part of her job responsibilities & will gladly help you.

All dialysis centers must have a MSW on staff to assist patients with obtaining/keeping insurance. 

His income on SSDI may take him over Medicaid eligibility but speak with the social worker. I have seen many dialysis patients as having both Medicare & Medicaid. He may be eligible for both.

Good luck!