Medicaid Case Study: Know Medicaid Application Processes—It Could Save You Money

Agency error-- which happens all the time.

PW, age 75, was previously approved for Community Medicaid as an individual. PW lived with his ex-wife that he only divorced because their previous counsel advised them that it would increase their chances of being approved for Community Medicaid. Even though the couple was divorced, they considered themselves to be a married couple. The couple presented themselves to the community as husband wife and Texas recognizes common-law marriage, therefore we were able to submit a long-term care Medicaid application for PW as one half of a married couple.

During the application process, HHSC sent out an H1020—Request for Information or Action. The clients received the notice later in the allotted response period. As such, the spouse did not have ample time to gather the requested supporting documents. To prevent a denial, the Michels Law Firm requested a delay of certification before the deadline, per MEPD H B-6510. The HHSC caseworker made an error and denied the case for Failure to Furnish.

As the client’s rights were violated during the application process, The Michels Law firm appealed the denial.

During the appeal, the HHSC Hearing Officer determined that the agency made an error and sent the case back to the caseworker to be processed properly. Even though the hearing officer sent the case back to the caseworker, there were months of no action on the case.

The Michels Law Firm filed a HEART Complaint with the Office of the Ombudsman against the State of Texas for non-action. Once there was interference from the Office of the Ombudsman, The Michels Firm was able to secure an approval for Long-Term-Care Medicaid for the client. The nursing facility was able to retroactively bill Medicaid for nine months of nursing home coverage. The facility collected over $35,000.00 in nursing home fees from the state.

PW and his wife would have had to pay $35,000 out of pocket if the denial could not be contested.