MASSHEALTH MIRACLES: HOW CAN YOU GET ONE OF YOUR OWN?

A large part of our practice is educating our clients and their families about long term care opportunities, helping them access the care most appropriate for their needs, and then helping them figure out how to pay for that care.  For many clients, the answer to “how do I pay?” is the Medicaid program, known here in Massachusetts as “MassHealth.”

The MassHealth application process is always very challenging.  Even for clients who have simple finances, it involves the collection and analysis and presentation of years’ worth of a client’s financial life.  It involves a back and forth between the client and the MassHealth agency over several months.  It often involves a disconnect between the actual black and white words of the Medicaid laws and regulations and the way that those rules are actually implemented by the MassHealth agency.  It involves working with an agency where there is no uniformity of process even though there absolutely should be.  Sometimes it seems like a combination of a scavenger hunt and that old TV show “Beat the Clock.” It always involves telling the client’s story.  And sometimes it involves a lengthy appeal process to change an initial “no” decision to a “yes.” It always generates considerable stress for the patient client (if he or she is able to understand) and for sure for his/her family.

Because hanging over the entire process is the prospect of often very large (as in thousands and thousands of dollars large) unpaid bills and health care vendors such as nursing home business offices very eager and anxious to be paid.

One of my absolute favorite moments in our elder law practice is when we are able to share with a client and her family that we just received a notice from MassHealth approving her application, with benefits beginning on the exact date that we requested.  Even when we have done everything exactly right, you just never know what a caseworker might do until we actually see those words on the page.  That approval notice is The Prize.  Sometimes it is even the key that is going to get a patient through the front door of a facility.

We appreciate that nursing homes want to be paid.  They certainly are entitled to be paid for the important services they are providing to our clients.  The Business Office staffs of nursing homes interact with the MassHealth agency on a daily basis and are very familiar with MassHealth’s billing and payment practices.  But the Business Office staffs … and the Medicaid application preparers to whom they often refer families for “free” help … are not attorneys.  Yes, they have their canned lists of documents that are generically needed to support applications.  Yes, their help can be useful for single patients who truly now have no money, and who have never really had any.  For anyone else, however, it is critically important to remember that “free” often comes with a big invisible price tag because there is a whole lot more to achieving The Prize than merely checking off some “yes/no” boxes and tossing some documents into an envelope.  Because it’s not just about trying to get a bed paid which is, understandably, the nursing home’s #1 priority.  The future financial life of the patient and his/her spouse and family is at also very much at stake.

Nursing homes aren’t in the business of worrying about that.  But we are.

Yesterday, we got The Prize for a client.  It was a very exciting moment because this has been a challenging matter with an uncertain outcome.  This client’s Medicare coverage for her nursing home bed had run out in early November.  Under the Medicaid rules, the client had until the end of February at the absolute latest to submit her application in order to get retroactive coverage back to November.  The Business Office manager at the nursing home offered to help the family with the Medicaid application (for free), and over a period of several months collected documents from the family.  The family relied on the manager’s advice on how to spend the client’s remaining funds, on the steps to take to prepay her funeral, on the documents that were needed for the application.  They had no reason to worry that any of the advice might be wrong, or that there might be options other than those suggested.  Because the nursing home manager knows what she is doing, right?

But then, several months into the process, the manager threw up her hands and suggested that an application would never be approved because of apparent issues with the patient’s finances, and said perhaps the family had better hire a lawyer after all right away.  And the facility began to threaten the patient and her family with discharge for failure to pay the ever-growing balance on the patient’s bill.  Talk about stress!  Especially since by that point the Medicaid rules dictate that any excess funds the patient might still have can be used to pay only medical or funeral-related expenses.  If she still wanted coverage to go backwards to November, she could no longer use any of her remaining funds to pay for an attorney.

The patient’s daughter came to us in a panic in mid-January with less than six weeks remaining on the application clock.  We accepted the challenge to help this family and got to work immediately.

Turns out this client’s finances were indeed complicated. And some of the advice given by the Business Office manager was not complete and had foreclosed other options that would have been available to the client had she known about them sooner.  The timely approval of this application was definitely not going to be a sure thing.  There was a lot of work to be done in a very short time frame in order to beat the clock.

I had a lot of questions, and gave the family a lot of homework. We did damage control, including advocating for postponement of the threatened discharge notice.  We answered the questions on the application differently than the Business Office manager had done on her draft (our way preserved the client’s house!).  We identified the potential problem areas, and addressed each of them through the way we presented the financial documents and by telling the client’s story through Affidavits (which are legal documents).  We advocated for our client with the MassHealth caseworker who asked for additional documents that were not in the client’s possession or control, and thereby headed off the need for a lengthy appeal of a denial of the application for “failure to provide verifications.” Many, many hours were invested in this process by our Firm, and by the client’s children in order to pull all of this off by the MassHealth deadlines.

And we did it.  We got The Prize.  This client’s bed will be covered by Medicaid, back to the very first day in November that benefits were needed.  Six months of stress end with a very well deserved long, deep breath by everyone involved.  Phew!

I can tell you with near absolute certainty that if the family had done this application by themselves … or had let the Business Office manager or her designee prepare and file this application for the client … The Prize would still be a fantasy.  The facility would still be upset and renewing their threats of eviction.  The family would still be upset and scared and stressed.  Months more would be spent tied up with an appeal whose outcome would be uncertain.  Remember that every day that is not covered by Medicaid is going to cost the patient $300 or more, depending on the facility.  Not exactly “free.”

If you or your loved one is about to enter a nursing home … or is already there … we welcome the opportunity to review your case.  We can help to minimize your stress, and can make sure that the nursing home gets paid in a timely fashion.  A win-win, all around.  Will our help be free?  Nope.  But remember:  you get what you pay for.  Hiring us to help you answer the question of “how do I pay?” gets you our years of experience preparing successful MassHealth applications, our in-depth understanding of both the words and agency interpretations of the Medicaid rules, our knowledge of your planning options, and our ability to protect both the patient and the family.  And will get you your very own Prize.  Pretty good deal.