The process of determining eligibility for Connecticut Medicaid nursing home benefits can be very complex. A quick look around the articles on this site shows how tricky some issues can be. Unfortunately, some families looking for legal help in obtaining Medicaid benefits choose an inexperienced attorney. When these cases go bad, they usually end up costing the family a lot of money in lost benefits, additional appeals, or even worse – both.

Today we will look at a recent case highlighting how a seemingly simple issue can go horribly wrong. Before we get into the legal discussion, let’s review the facts of the case.

1.  [FB] has been in a nursing home since September 13, 2004.

2. [The plaintiff, FB's spouse and conservatrix] resides at home in the community.

3. When determining Medicaid eligibility. . . an assessment of spousal assets is completed using the assets that existed as of the date of the beginning of the initial continuous period of institutionalization…

5. On February 28, 2005 an application for Medicaid was submitted to the Department on behalf of [FB].

6. In August 2005, [the plaintiff] hired an attorney to help her complete the Medicaid application process.

7. The attorney assumed the Department had already completed the spousal assessment when [the plaintiff] hired him.

8-12. Between March 28, 2005 and July 24, 2006, the Department sent numerous requests for documentation to [FB] and [when retained, the attorney] … [Until June 2006], the spousal assessment could not be completed because the Department did not have sufficient verification to complete the assessment.

13. On June 27, 2006, the Department had sufficient verification to complete the assessment of spousal assets and sent the results to [FB and the plaintiff]. The Department determined that in order for [FB] to be eligible for Medicaid, the couples assets would need to be reduced to $38,468.

14. On August 24, 2006 the Department approved Medicaid for [FB] effective June 1, 2006. The Department denied Medicaid coverage for the time period February 2005 through May 2006 because [FB's] assets exceeded the allowable limit.

15. [FB] reduced his assets within the allowable limits in June 2006.

18. [FB] exceeded the Medicaid asset limit for the months of February 2005 through May 31, 2006. The hearing officer concluded:

The Department is not at fault for not specifically directing the reduction of assets until June 2006, when the assessment of spousal assets was completed. The Department met its obligation to inform [FB] of what had to be done to establish eligibility, once it received the requested asset verification.

Although [FB] retained counsel six months into the application process, the attorneys and [FBs] lack of knowledge that a spousal assessment had not been completed does not preclude the counting of those assets toward the asset limit. The record reflects that the attorney did not inquire to the Department regarding the results of the spousal assessment. In addition the record reflects that [the spouse and the attorney] were advised beginning in February 2006 that an assessment had not yet been completed due to insufficient evidence.

The Issue

The issue in this case is what is the starting date for receiving Connecticut Medicaid nursing home benefits? The Department of Social Services determined the plaintiff’s spouse can receive benefits starting June 1, 2006 – the date the spousal assessment was completed revealing eligibility for benefits. The plaintiff family argued that they should receive benefits from earlier than June 1, 2006 because either (1) it was the Department of Social Services’ responsibility to complete the spousal assessment since April of 2005 or (2) they were eligible for benefits before June of 2006 even if the spousal assessment was not completed to document eligibility.

The Spousal Assessment

The assessment of spousal assets is a crucial step in the application process. It is critical to determining who gets to keep what when one spouse applies for Connecticut Medicaid nursing home benefits. The regulations provide: “The Department provides an assessment of assets. . . at the time of application for Medicaid whether or not a request is made.” The request for a spousal assessment in this case was filed in April 2005.

Case closed – right? After all, the family requested an assessment of spousal assets in April of 2005 yet the Department of Social Services did not provide the assessment until June of 2006.

The court did not agree with that interpretation. The court relied on procedural regulations created by the Department of Social Services that provides in part: If you did not get information or verification of assets, do not complete an assessment.§1507.05.6. Further §1507.10.4 provides: Complete the evaluation of the assessment within 45 days of the receipt of all the required documentation.

So, even though the assessment of spousal assets to determine eligibility for Connecticut Medicaid nursing home benefits was requested in April of 2005, the family – and later the family’s attorney – failed to provide the Department of Social Services with the information needed to complete the assessment of spousal assets until June of 2006.

When that argument was lost, the plaintiff family attempted to argue that there was no meaningful change in assets from April of 2005 through June of 2006. Specifically, the plaintiff family claimed at the administrative hearing that the verification went on too long and that the assets were the same in early stages of application as they were when the assessment was issued in June 2006.

The court did not find the plaintiff family’s assertion supported in the record. The DSS worker testified that there were additional bank accounts to run down, and there was an issue of when FB entered into continuous care. The plaintiff’s own attorney contributed to the delay when he claimed there was a probate proceeding needed to develop what was what.

The court also found the record supported the conclusion of the hearing officer that the attorney for the plaintiff assumed that the spousal assessment had been completed before he became involved in the case. If the attorney had contacted the worker after being told that the spousal assessment was not completed, he would have been able to gather preliminary figures to assist in paying down assets.

The Conclusion

The family lost their case. The court upheld the Department of Social Services’ decision to provide benefits retroactive to June of 2006 rather than earlier as they had sought to obtain. The family is responsible for paying the nursing home bills for those months of delay as well the costs incurred in appealing the decision.

How To Avoid the Same Fate

Know what you are doing. If you are not up on the latest Connecticut Medicaid cases and regulations, then hire an experienced Connecticut Medicaid attorney to guide you through the process. The family in this case hired an attorney who unfortunately made a costly assumption to the detriment of his client. This family may have enjoyed a different fate if their attorney took five minutes to confirm the assessment of spousal assets was actually completed when he was hired or took steps to complete the assessment shortly after he was hired.

Applying for Connecticut Title 19 Medicaid benefits can be tricky. Some of the questions on the application may seem straightforward while others may seem downright confusing. Assuming you submit a completed application for Connecticut Title 19 Medicaid benefits what happens after you have been denied?

A lot of people are denied for Connecticut Medicaid benefits after their initial application. The reason why their application is denied could be any number of reasons. In some cases the application is incomplete or inaccurate. In some cases assets may be attributed to the applicant when they should not be. In some cases you may be entitled to Connecticut Medicaid benefits but the way the system is set up, it is just not within the power of the case worker to approve your application. This last case is very common with married couples.

Whatever the reason, if you have been denied Medicaid benefits the clock starts ticking. You can accept the decision and spend down your assets, perhaps more than you need to; or you can appeal the decision and request a hearing.

If you plan to appeal, you only have a limited amount of time. At the appeal stage you are facing a hearing with an administrative law judge that will base their decision to approve or deny your application on their interpretation of the relevant laws and administrative regulations. A Connecticut Medicaid Attorney can represent you and help present your case at this hearing.

The Special Focus Facility program is a great tool for the Centers for Medicare and Medicaid Services as well as for consumers. I don’t image many nursing home facility administrators brag about their participation in the SFF program so this is one of those things you need to research on your own.

Connecticut had only two facilities on the most recent Special Focus Facility report. Chelsea Place Care Center is included in the list of nursing homes that have shown improvement while being a Special Focus Facility for 11 months. The Wethersfield Health Care Center is also identified as showing improvement while being in the SFF program for 37 months. Hopefully Wethersfield Health Care Center will graduate from the program soon after such a prolonged stay.

Additional information on what the Special Focus Facility program is and what it means to you as a consumer can be found here.