Medicaid appeals for denial of nursing home or assisted living coverage in Florida will almost certainly increase. According to one projection, Florida is expected to add 250,000 new residents per year for the next seven years. The same projection indicates more than one in four Florida residents will be 65 or older by 2030. And that shouldn’t come as a surprise. Along with its sparkling beaches, vibrant cities and temperate winter climate, Florida boasts lesser known, but important amenities attracting older Americans. These include hundreds of licensed nursing homes and thousands of licensed assisted living facilities.
The trouble is that space is limited. In fact, one estimate puts occupancy in Florida’s licensed nursing homes at 85 percent at any given time. To further complicate matters, long term care isn’t cheap. The median annual cost of care for a private room in a licensed nursing home is more than $100,000, while the median annual cost of care for a semi-private room is nearly $90,000.
Given that, it may not come as a surprise to learn that Medicaid – the program that covers health care costs for some people in nursing homes and assisted living facilities – accounts for most of all long-term care spending. Additionally, Medicaid payments cover the cost of more than half of all Florida nursing home residents. Given this situation then Medicaid appeals for denial of nursing home or assisted living coverage will go up.
Of course, all of this begs an important question. What happens if Medicaid denies your request for nursing home or assisted living coverage? Fear not. You can always appeal.
Medicaid Appeals for Denial of Nursing Home or Assisted Living Coverage in Florida Explained
Requesting Medicaid coverage for nursing home or assisted living coverage in Florida is a complex process. As part of this process, you must provide comprehensive documentation proving you meet eligibility requirements.
Medicaid may reject your request if you don’t provide all of the required information within the required time limit, or if you don’t meet one or more eligibility requirements. Specifically, the Medicaid agency may reject your application if your assets exceed the allowable limits. It may also deny your request if you transferred assets for less than market value within a specified period in order to meet eligibility limits.
In any case, the Medicaid agency that denies your request must issue a denial notice within 45 after receipt of your application (or 90 days if you requested coverage based on a disability). This notice must include certain information, such as the reason for denial, how to appeal, and the deadline for filing an appeal. The deadline is typically 30 to 90 days after receipt of the denial notice.
Once Medicaid gets your appeal, it will set a hearing date. You are allowed to have people testify for you, and you are allowed to question the Medicaid agency’s witnesses during the hearing. Having a lawyer to represent you at the hearing isn’t required but it is recommended.
Requesting a Fair Hearing After Denial of Nursing Home or Assisted Living Coverage in Florida
All applicants appealing Medicaid denial of nursing home or assisted living coverage must be informed about their right to a Fair Hearing. In 2017, however, new rules took effect pertaining to the hearing process for Medicaid programs managed by the Agency for Healthcare Administration (ACHA). These programs include the Statewide Medicaid Managed Care program for long term care.
If you are already enrolled in the Statewide Medicaid Managed Care program for long term care, you must complete the applicable plan’s grievance and appeal process before requesting a Fair Hearing. You can only file for a Fair Hearing if the initial denial is upheld. If the initial denial is upheld, you should get an official notification called a Notice of Adverse Benefit Determination (NABD). The NABD must include instructions on how to file for a Fair Hearing.
An advocate should request a Medicaid Fair Hearing through the ACHA when he or she disagrees with denial, reduction, suspension or termination of Medicaid service or services made by ACHA for regular Medicaid or Statewide Medicaid Managed Care program. The notification of denial, reduction, suspension or termination of services must include instructions on how to file for a Fair Hearing and the filing deadline, which is usually 90 days after denial.
Do you need an attorney for Medicaid Appeals for denial of nursing home or assisted living coverage in Florida? That is a good question. To learn more on why you are likely to come out better in using an attorney, you can download our free eBook on Protecting Your Family’s Assets from the Unlicensed Practice of Law now.
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To learn more about following denial of your application for nursing home or assisted living coverage, don’t hesitate to give us a call. You can reach us at 727-260-2581 or at 813-431-3193 after 5 p.m.