Steps in the Medicaid appeals process

Steps in the Medicaid appeals process

On Behalf of | Feb 1, 2021 | Long-Term Care Facilities |

As the administrator of a long-term care facility, you know the importance of Medicaid, also known as Medical Assistance (MA) in Pennsylvania. Unfortunately, many elderly residents would not be able to afford the care they need without this government assistance. When the acting county authority denies your potential resident initial MA benefits or fails to renew a current resident’s benefits, you should know what steps you can take to help your resident appeal that decision.

Step one – Request a hearing

Your resident can file a written request with the Bureau of Hearings and Appeals (BHA) within 30 days of a written notice of denial. BHA will docket the appeal and schedule a hearing before an administrative law judge (ALJ). They will send a notice to your resident and the Department of Human Services (DHS).

Step two – Prepare for the hearing

Your resident and/or their family may hire their own attorney to help with this process. If not, you may determine that your own legal advisor is a worthwhile investment. To prepare for the hearing, you want to pinpoint where you believe DHS erred in its eligibility assessment and gather the necessary paperwork to highlight the mistake.

Step three – Attend the hearing

The BHA may hold hearings in person or over the telephone in Pennsylvania. As with everything else, more have been handled virtually recently. The hearings are informal, but the judge will collect the evidence, including testimony and documents, from each side.

Step four – The decision

The ALJ may decide the case right in the hearing with an oral decision, or wait to issue a written adjudication. The BHA director will review the decision to affirm, amend, remand or reverse if they do not agree with the ALJ.

Wrongful denials of eligibility can cause coverage gaps and cost your facility needed revenue, not to mention putting your residents at risk. When you see a problem, don’t be afraid to pursue an appeal.