Obtaining Retroactive MassHealth Benefits

by Matthew Karr, Esq. on May 25, 2011

Oftentimes, clients seeking Medicaid benefits in Massachusetts (MassHealth) for their loved ones have already incurred costs associated with long-term care. If your loved one enters a nursing facility and then applies for MassHealth, it can be months before a final approval is received, and all the while the nursing home bills will be mounting. Fortunately, if strict procedures are followed, MassHealth allows for retroactive benefits up to three months prior to an application. If you are not careful, however, this retroactive coverage can be lost and you may end up footing the bill.

MassHealth applicants can receive retroactive coverage for the costs of long-term care up to the first day of the third month prior to submitting an application. However, to preserve this application date, and therefore the period of retroactive benefits, you must keep the original application ‘alive.’ If an applicant receives a denial due to missing information and then mails in the missing information within thirty days of the denial, that action is treated as a new application. This will create a new application date, which will then affect the maximum time period that MassHealth can be applied retroactively.

To avoid this outcome, a MassHealth denial should be appealed. A successful appeal of a MassHealth denial will keep the original application alive, thereby preserving the original application date. If you were to simply send in the missing information after a MassHealth denial, your right to appeal and the needed retroactive period could be lost.

Similarly, the treatment of previously-paid expenses can be affected by the timing of a MassHealth application. Medical and nursing home expenses that are incurred less than ninety days prior to an application are allowed to be paid as part of the spend-down process. However, if the original application date is not kept alive, those expenses could be considered to precede the MassHealth application by more than ninety days and not be allowed as part of a spend-down plan.

When these time-sensitive procedures are not followed correctly, the result can be that the MassHealth applicant will be held responsible for the unpaid amount that MassHealth won’t cover retroactively. With the costs of nursing care reaching $10,000 per month, this can be a significant penalty. As a last resort, an applicant could request to MassHealth that the unpaid nursing home bill be paid over time via deductions from their monthly income. However, while MassHealth would have been required to cover the bill if the appeal process had been correctly followed, there is no guarantee that MassHealth would make any concessions toward disallowed nursing home bills. To make sure your MassHealth application is done right the first time, contact a Massachusetts elder law attorney.

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