Pennsylvania Medicaid Audits Raise Concern
After a Medicaid nursing home application has been granted and Medicaid is safely in place to cover the cost of care for a loved one, one would think that financial issues have been resolved and there is no more need for vigilance. That may not be true especially under recent policy in Pennsylvania.
Medicaid audits both for nursing home residents and for those receiving Medicaid in the community have been accelerated and people who are now on Medicaid and their families need to be attentive so that they do not lose it. This is how.
First, it is important to understand how people qualify for nursing home Medicaid initially. They need to be certified as needing a certain level of medical help, a certification called NFCE or Nursing Facility Clinically Eligible, which often comes from the County Area Agency on Aging. In Chester County this is the Department of Aging Services. They also have to have assets down to Medicaid levels. Where there is a spouse at home, there are special rules to allow the at-home spouse to keep more and, in some cases, to receive a portion of the nursing home spouse’s monthly income. If the family plans early enough, there are special rules that might also allow them to keep additional assets but they need to seek help early on.
Once someone is on Medicaid, that person needs to keep liquid assets in his or her name including bank and investment accounts down to a given figure. That figure might be $2,000 or $2,400 or $8,000 depending on the rules to be applied. If they exceed that amount at any time, Medicaid might be temporarily or permanently suspended.
As to the spouse at home, after Medicaid for his wife or her husband is granted, he or she is free to earn money on investments, to buy and sell property and otherwise to conduct business as usual with one exception. Pennsylvania does not want spouses at home to sell their home and keep the cash proceeds from the sale of the home. This last issue is a relatively recent development and raises questions that go beyond the scope of this column.
Into all of this comes the Medicaid audit.
After a person has been on Medicaid, the government might send a request for updated financial information. This was done in the past but has been stepped up recently. Typically, the Medicaid recipient is given a form and is told to answer with updated financial information within ten (10) days. If no response is received or if the response states figures higher than the allowable amounts, then a “redetermination” might be issued revoking the Medicaid benefit.
Obviously, there can be several problems here. One can be the U.S. Mail. The Medicaid recipient might not receive the mailing and so, might not respond. Another problem for people who are not familiar with the forms is that they might not understand how to respond. For instance, a spouse may not understand that his assets and his wife’s assets are not to be combined in the answer. Also, a Medicaid recipient might briefly have assets higher than the asset limit before paying the nursing home or medical bills.
Although my firm’s work is primarily with Medicaid recipients in nursing homes, this Medicaid problem stretches to Medicaid recipients in the community.
The Pennsylvania Mental Health Consumers’ Association recently sent an alert stating: “The Department of Public Welfare has looked for ways to cut spending. Much effort has been put into finding fraud, waste and abuse. It was recently reported by DPW that at least 100,000 Medicaid cases were closed when redeterminations of eligibility were sent to people who were given 10 days in which to respond to their Public Assistance offices. It is necessary to find people who lost their Medicaid eligibility in the past few months in order to find out if the case closures were done properly or improperly…” The notice went on to give information how to contact them. See www.pmhca.org.
In the short term, it is important to note that any mailing from Department of Public Welfare or from local Assistance offices should be opened and responded to as soon as possible in order to avoid similar problems and loss of benefits.
For more, listen to “50+ Planning Ahead” a weekly radio program on WCHE 1520 on every Wednesday from 4:30 pm to 5:00 pm with Janet Colliton, Colliton Law Assocs., PC, and Phil McFadden of Home Instead Senior Care.
About the Author Janet Colliton
Esquire, Colliton Law Associates, P.C. Janet Colliton has practiced law for over 38 years, 37 of them in Chester County, Pennsylvania, a suburb of Philadelphia. Her practice, Colliton Law Associates, PC, is limited to elder law, Medicaid, including advice, applications and appeals, and other benefits planning including Veterans benefits, life care and special needs planning, guardianships, retirement, and estate planning and administration.