Applying for Medicaid can be a complex and time consuming process but understanding the steps involved can make it significantly easier. Medicaid provides health coverage and long term care benefits to millions of low income Americans including seniors, people with disabilities, and families with children. This guide explains how the application process works and what to expect.
What Medicaid covers
Medicaid covers a broad range of health and long term care services including doctor visits, hospital care, prescription drugs, mental health services, and for eligible seniors long term nursing home care. The specific services covered vary by state because each state administers its own Medicaid program within federal guidelines.
Who is eligible for Medicaid
Medicaid eligibility is based on income and in some cases assets. Eligibility rules vary significantly by state and by the type of Medicaid coverage being sought. General categories of eligibility include:
- Low income adults
- Children from low income families
- Pregnant women with limited income
- People with disabilities
- Low income seniors aged 65 and older
- People who need long term nursing home care and meet financial eligibility requirements
Since the Affordable Care Act many states have expanded Medicaid to cover adults with incomes up to 138 percent of the federal poverty level regardless of whether they have children or a disability. However not all states have adopted this expansion so eligibility rules vary.
Types of Medicaid applications
There are two main types of Medicaid applications depending on what coverage you are seeking:
- Standard Medicaid — for general health coverage including doctor visits, hospital care, and prescription drugs. This is the most common type of application and is typically processed through your state’s health insurance marketplace or Medicaid agency.
- Long term care Medicaid — for coverage of nursing home care or home and community based services. This type of application involves a more detailed financial review including a five year look-back period for asset transfers and is typically more complex than a standard Medicaid application.
Where to apply for Medicaid
There are several ways to apply for Medicaid depending on your state:
- Your state’s Medicaid agency — every state has a Medicaid agency that processes applications. Contact information is available at medicaid.gov.
- Healthcare.gov — the federal health insurance marketplace allows you to apply for Medicaid coverage online. If you are determined eligible your application is transferred to your state’s Medicaid agency for processing.
- Your local Department of Social Services — many states allow Medicaid applications to be submitted in person at local social services offices
- A hospital or healthcare provider — many hospitals have eligibility workers who can help patients apply for Medicaid coverage
- A certified application counselor or navigator — trained professionals who can help you complete your Medicaid application at no cost
What you will need to apply
The specific documents required vary by state but most Medicaid applications require:
- Proof of identity such as a driver’s license, passport, or birth certificate
- Proof of residency such as a utility bill or lease agreement
- Proof of citizenship or immigration status
- Social Security number for each person applying
- Proof of income including pay stubs, tax returns, Social Security award letters, and pension statements
- Proof of assets including bank statements, investment account statements, and property records — required for long term care Medicaid applications
- Documentation of health insurance coverage if any
- For long term care applications five years of financial records including bank statements, tax returns, and records of any asset transfers
The long term care Medicaid application process
Applying for long term care Medicaid — the type that covers nursing home care — is significantly more involved than applying for standard health coverage Medicaid. The process typically includes:
- Gathering financial documentation — collecting five years of bank statements, tax returns, investment account records, and records of any asset transfers or gifts
- Completing the application — filling out a detailed application that includes information about income, assets, and medical needs
- Medical needs assessment — a state assessor evaluates whether the applicant meets the medical necessity criteria for nursing home level care
- Financial eligibility review — the state reviews the applicant’s income and assets to determine financial eligibility and calculates any penalty periods resulting from asset transfers during the look-back period
- Notification of decision — the state notifies the applicant of the decision. If approved Medicaid coverage begins as of the approval date or in some cases retroactively.
How long does Medicaid approval take
Processing times vary by state and by the type of application. Standard Medicaid applications are typically processed within 45 days. Long term care Medicaid applications which involve a more detailed financial review can take 45 to 90 days or longer depending on the state and the completeness of the application.
Submitting a complete and well documented application is one of the most effective ways to avoid delays. Missing documents are one of the most common reasons for processing delays.
What happens if your application is denied
If your Medicaid application is denied you have the right to appeal the decision. The denial notice will include information about how to request a fair hearing — a formal review of the decision by an administrative law judge. You have a limited time to request a hearing after receiving the denial notice — typically 30 to 90 days depending on the state.
Common reasons for Medicaid denial include:
- Income or assets above the eligibility limit
- Incomplete application or missing documentation
- Failure to meet medical necessity criteria for long term care
- A penalty period resulting from asset transfers during the look-back period
An elder law attorney can help you understand the reason for denial and determine whether an appeal is appropriate.
Getting help with the application
Because long term care Medicaid applications are particularly complex many families choose to work with an elder law attorney or a Medicaid planning specialist. These professionals can:
- Evaluate your eligibility and identify planning strategies to help you qualify
- Help gather and organize required documentation
- Complete and submit the application on your behalf
- Respond to requests for additional information from the state
- Represent you in an appeal if your application is denied
Veterans service organizations such as the American Legion, VFW, and DAV also provide free assistance with certain types of benefit applications.
Medicaid and estate recovery
An important aspect of Medicaid that applicants should understand is estate recovery. Federal law requires states to seek reimbursement from the estates of deceased Medicaid recipients for the cost of certain services including nursing home care. This means that after a Medicaid recipient dies the state may make a claim against their estate to recover the cost of benefits paid.
Estate recovery rules vary by state and there are important exceptions including protections for surviving spouses and certain other family members. Understanding estate recovery is an important part of Medicaid planning especially for people who own a home.
Key terms to know
- Medicaid — a joint federal and state program providing health coverage and long term care benefits to eligible low income individuals
- Look-back period — the five year period during which Medicaid reviews asset transfers when determining long term care eligibility
- Penalty period — a period of Medicaid ineligibility resulting from disqualifying asset transfers during the look-back period
- Fair hearing — a formal appeal process available to applicants whose Medicaid application has been denied
- Estate recovery — the process by which a state seeks reimbursement from a deceased Medicaid recipient’s estate for the cost of benefits paid
- Medical necessity — the requirement that an applicant’s medical condition requires the level of care for which coverage is being sought
- Elder law attorney — an attorney who specializes in legal issues affecting older adults including Medicaid planning and applications
Sources
- Medicaid.gov — Official U.S. Government Medicaid Information
- Centers for Medicare and Medicaid Services
- National Academy of Elder Law Attorneys — naela.org
- USA.gov
For state-specific Medicaid eligibility limits and resources visit our State Elder Care and Estate Planning Resources page.
This article is for general informational purposes only and does not constitute legal or financial advice. Medicaid rules vary significantly by state and are subject to change. Consult a licensed elder law attorney or contact your state’s Medicaid agency for guidance specific to your situation.