As an attorney for Rothkoff Law Group, I help support our Public Benefits staff with complicated Medicaid issues and unexpected application outcomes when applying for Medicaid. As a result, I have found the internal processes of state Medicaid agencies processing Medicaid applications do not always comply with state and federal Medicaid laws, often to the detriment of our clients. For this reason, it is essential to have an advocate when applying for Medicaid for long-term care in both New Jersey and Pennsylvania.

It is worth noting I do not believe the Medicaid agency’s occasional failure to comply with Medicaid rules and regulations is intentional. Most of the county Medicaid offices have an overwhelmed staff inundated with Medicaid applications. Under the circumstances, I can understand how issues are overlooked or are chronically misunderstood. Unfortunately, most Medicaid applicants are not going to know when the state Medicaid agency is not complying with the law.

For over 18 months, I worked on a case centering on the retroactive Medicaid eligibility rule. This rule requires the Medicaid office to assess an applicant’s eligibility during the three months prior to the month of application. For instance, if someone applies for Medicaid in June, the applicant can receive Medicaid benefits as far back as March if she is eligible for benefits in March.

The county Medicaid office denied our client’s Medicaid application because she was not Medicaid eligible in the month the county physically received her application. The county contended since the applicant was not eligible in the month the application was received, it did not need to be reviewed for retroactive coverage. Our elder care law office recommended and helped our client implement an asset protection plan by having the healthy spouse purchase an immediate annuity with the excess spousal assets in order to protect the remaining assets for the healthy spouse. As a result, the county argued the client was not eligible in the month the county received the application. (Information on the benefits of a spousal annuity Medicaid planning can be found here.) The county’s position was contrary to state and federal law. Had the county reviewed the application for eligibility during the three months prior to receiving the application, it would have found the client eligible.

Initially, I believed the case would be easily resolved because the retroactive rule is clearly stated in law. I was wrong. After finding no common ground with the caseworker, her supervisor, and counsel for the county, I appealed the county’s denial of the application. After a briefing process, the appeal was reviewed by an Administrative Law Judge (ALG), who ruled in support of my

client. Then, per New Jersey Medicaid regulations, the ALJ’s decision was reviewed by the NJ Director of Division of Medical Assistance and Human Services, who agreed with the ALJ by also ruling in favor of our client. However, that did not end the case. The county needed to re-review the application for Medicaid eligibility. The review process took several months and repeated follow up. Finally, 18 months after the application was initially denied, the county approved the application. Our client was given 19 months of retroactive Medicaid coverage.

What this means: We saved our client almost $200,000 in total care costs.

Without an advocate who understands state and federal Medicaid rules and regulations, applicants are risking the ability to access long-term care services and funding.

If our client did not have us to fight for her, she and her husband would have lost the $200,000 her husband was legally entitled to retain.