Denied MassHealth? How to Challenge a Nursing Home Decision

Denied MassHealth? How to Challenge a Nursing Home Decision

Decisions made by Medicaid, known as MassHealth in Massachusetts, can be challenged. If you applied for MassHealth as part of the process for getting into a nursing home and were denied MassHealth, you have the right to appeal the denial.

Reasons for MassHealth Denial

Common reasons for Medicaid / MassHealth denial include the following:

  • Income is too high to be eligible
  • Value of assets is too high for eligibility
  • In cases of disability, the state MassHealth agency did not believe you were sufficiently disabled to qualify
  • Supporting information requested was not provided

Here is an overview of what you should know about the denial of the application and how to proceed after receiving it.

Your Denial Notice

If you were denied Medicaid by MassHealth, you should carefully read the denial notice. The state has 45 days from your application date to submit the denial notice if you applied for MassHealth for reasons other than disability. Moving into a nursing home is one such reason.

Your notice will include important information that will affect how you proceed with the case. It must inform you of:

  • why your application was denied,
  • the specific rules that went into the denial,
  • your right to appeal the denial at a hearing,
  • how to request a hearing, and
  • the deadline for requesting an appeal.

Be sure to keep the document for your records.

The Appeal

To appeal the MassHealth denial, you can hire an attorney, represent yourself, or have someone else act on your behalf or assist you with your case. MassHealth will handle the appeal in accordance with federal Medicaid appeal guidelines.

IMPORTANT: You must request your appeal by the deadline listed on the document.

You may need to make the appeal request in writing, but you might also be able to do it in person or over the phone. Again, carefully read the notice you receive.

Once you have a date for your hearing, you must appear for the hearing or potentially have your case dismissed. You will receive information from MassHealth about how your hearing will proceed and information about location, time, and date.

To increase the chance of success in your hearing, an attorney who specializes in elder care and Medicaid may be able to help you qualify. An attorney can (1) help gather all the necessary documentation, and (2) help prove your assets and income are below the threshold necessary to qualify for nursing home care with MassHealth assistance.

For disability claims, you might need to order a medical exam to document the disability.

Retroactive MassHealth

If you win your hearing, you may be able to seek retroactive coverage for the time and payments you lost after initially submitting your application.

To learn more about the specific actions you can take when planning for MassHealth and nursing home care, Baker Law Group P.C. offers a free initial consultation with an experienced elder law attorney. We would appreciate the opportunity to speak with you.

To schedule a consultation:

Complete Online Form or

781-996-5656 Call Email

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