Medicaid Coverage and Medicaid Appeals

Coverage

Medicaid coverage is broader than Medicare. However, obtaining care can sometimes be more difficult. Medicaid covers prescriptions, nursing home care, home health care, doctor visits, and hospitalization. Some state plans also cover dental care, eye care, hospice care, and therapy. Contact your local agency on aging for information about your state plan.

The problem with Medicaid is that it can be difficult to find a provider. All hospitals are required to accept Medicaid, but nursing homes that choose to accept Medicaid have a certain number of available beds for Medicaid patients. Many doctors will not accept Medicaid patients, forcing Medicaid patients to use busy clinics with long waiting times.

Medicaid provides retroactive coverage for nursing home care for up to three months before you apply for Medicaid, as long as you would have been eligible during that time period. The facility providing coverage must accept Medicaid payment as payment-in-full.

Not all facilities have to accept Medicaid. Only certified providers must accept Medicaid payment. Medicaid provides unlimited coverage for nursing home stays and for assisted living (if assisted living is covered by the state Medicaid program).

Appeals

To appeal a denial of Medicaid coverage, you must receive a notice of a reduction in benefits. You have ten days to respond to it and request a hearing. You are entitled to a fair hearing in front of a hearing officer within ninety days of your request. Your benefits must be continued during this time. The hearing is an informal administrative proceeding. The government must show that it followed the law in denying coverage. You have the right to appear, have an attorney, and call witnesses. A detailed letter about your condition and treatment from your doctor is an important piece of evidence to bring to a hearing. If you are denied coverage in the fair hearing, you need to follow your state’s individual procedures for appeals. These vary from state to state. Contact your local agency on aging for details on your state’s procedures.