Autumn 2011 Newsletter
season, we publish a Newsletter that, more times than not, explains what
the law is, its substance. Our current issue will focus, instead, on how
the agency that executes the law, here, Medicaid, actually functions
when you submit an application. As most of you already know, the new
Medicaid levels for 2012 have been released: monthly income is limited
to the amount of $792 and resources are limited to the amount of
But how does the Medicaid office operate? What happens when an
application is submitted to the local office? We thought that we would
present a brief description of the main points in the process so that
you, the reader, may have a better idea of what is needed to complete
The Medicaid Program
Medicaid, a needs-based health program for Americans and legal,
permanent residents, is funded by both the state and federal
governments, and covers the medical expenses of those in the community
and in nursing homes. The federal government sets broad guidelines, and
then each state sets its rules within those guidelines. Accordingly, it
is important to recognize that each state’s rules may vary; however, for
the purposes of this article we will discuss the New York view.
Currently, Medicaid pays for approximately 60% of the medical costs for
all nursing home residents.
The first step in the process of obtaining Medicaid is the preparation
and submission of the form, New York Health Care application form 4220
which, if you require institutional coverage, must include the Access
New York Supplement A. These forms can be obtained over the internet
(New York State Department of Health website) or by telephone request
(718.557.1399.) In addition, documentation proving age, citizenship,
residency, marital status, income and resources should be submitted
contemporaneously with the forms; photocopies are fine. I would urge all
applicants to oversee this process personally; handing over this job to
a caseworker in a health-care facility may not benefit the applicant in
the long run.
Once the application is submitted to the local Medicaid office, then a
caseworker is assigned. She will commence her investigation based upon
the documents and forms submitted. It is expected that the applicant
will cooperate with the caseworker, and when a request is made for
additional information then the applicant will provide what is
requested. Failure to cooperate will result in a denial.
The application process, which includes
the submission of required forms and supporting documentation, is
contingent upon the type of services that the applicant seeks.
Medicaid Home Care
When applying for Medicaid home care, also known as personal aide
services, within the City of New York, a physician-prepared form M11q
must accompany the application. It is crucial that the applicant select
a physician with relevant experience in both geriatric medicine and in
completing this form. Even better is the physician who will provide a
supporting affirmation with the M11q. Outside the City of New York, a
physician’s order form must accompany the application. (Check with local
Medicaid offices to determine which form must be submitted.)
Once the physician’s report is received by Medicaid, a caseworker is
dispatched to the home of the applicant to evaluate his needs
on-site. If approved, then a determination must be made as to the number
of hours and days per week that Medicaid will cover the medical costs
for the aide. Twenty-four hours a day, seven days per week coverage is
rarely approved, absent truly extraordinary circumstances.
Medicaid Institutional Care
In a sense, this application is somewhat less onerous for the applicant
than the home care application as her very presence in a facility for
long term care proves medical need. In addition to the basic application
and supplement, the applicant will have to provide a MAP 648 nursing
home form, MAP 751 consent, and Medicare Buy-In Eligibility Review Form.
Notification of the
If the application is granted, Medicaid notifies the applicant, in
writing, with a budget that explains the Medicaid coverage in
detail. Ordinarily, Medicaid recipients can expect to receive a
recertification form six months after the date of acceptance, which must
be filled out and returned in a timely manner to keep benefits
on-going. An initial acceptance grants Medicaid coverage for a maximum
of three months retroactive from the date of the application.
If the application is denied, the applicant should request a fair
hearing appeal if she believes an error has been made by Medicaid. It is
important to file that request within sixty days of the denial because
by doing so the applicant preserves the original application date and
its retroactive period, a period of coverage that would be lost if an
entirely new application was submitted.
The above list is for general information purposes only. It is not intended to constitute individual legal advice or a specific recommendation to any particular client.
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