In our day-to-day work representing skilled nursing facilities, we are regularly asked by our clients to assist in securing Medicaid benefits for their residents. This often entails seeking the cooperation of the resident or their legal agent in the Medicaid eligibility process. In these situations, one of the first things I look to do is arrange a conversation with whomever has authority to act on behalf of the resident, be that the resident him or herself if they have capacity, or their Power of Attorney or Guardian (or Conservator) if the resident does not have capacity.

By the time the matter comes to us, there was typically some earlier refusal to proceed with the Medicaid eligibility process that took place, be that in submitting a Medicaid application, spending down excess resources, or some other tasks required to secure an award of Medicaid benefits.

Below are some tried and true methods I use to secure cooperation in the Medicaid eligibility process. These are effective. Usually, after this initial conversation, I can secure the necessary cooperation and can quickly proceed with the steps required to obtain Medicaid eligibility on behalf of the resident. However, they are not foolproof. Below I also offer some options to consider if, after the conversation with the resident or their legal agent, there is still a refusal to cooperate.

WHY A CONVERSATION?

Very often, I will prepare a written letter to the resident or their legal agent requesting their cooperation in the Medicaid eligibility process. This can be effective and a good first step to initiate a dialogue, but usually, it is the one-on-one conversation that is most effective. A letter is less genuine, less personal, and is not a dialogue where I can engage in a discussion about these complicated issues and intrusive personal questions. There can be trust issues involved in the resident agreeing to give up financial information and discussion of their hard-earned assets. A conversation with a person is more personal than a letter and is a true back-and-forth, as opposed to a letter, which can be easily discarded.

WHO AM I?

Persons who find themselves in skilled nursing facilities can be overwhelmed with all the myriad of people they encounter. There are doctors, nurses, business office personnel, ombudsmen, insurance providers, pharmacists, and on and on. At the start of the conversation, I explain very clearly who I am and why I am asking them to talk to me. This typically involves a description of my role, the facility’s need for payment, legal impact and other implications related to potential discharge, continued care, and other personal, financial, and medical issues such as ongoing asset management.

GOSH DARN UNCLE SAM

If cooperation is an issue, usually somewhere in the conversation I will point out that these burdensome, complicated, and annoying rules to secure Medicaid benefits were not created by the skilled nursing facility, but by the state Medicaid agency and the federal government. I will usually point out that all skilled nursing facility residents are subject to the same burdensome Medicaid eligibility rules. Nothing is more uniting that complaining about government regulations. This is very effective because in many instances the resident does not know why they are being asked to give up their financial information and have suspicions that it is a result of someone trying to take advantage of them. Explaining that these are not the skilled nursing facility rules goes a long way to putting them into a position to understand the basic framework and is not done simply to be nosy into their personal and financial affairs.

THE NITTY GRITTY

I will usually start with an explanation of the basic framework of the Medicaid eligibility process and then attempt to get secure basic information about assets and income. Because the rules can be complicated, I make sure to explain the reason for each question that I ask. I never rush it.

It's important to keep in mind that while I have vast knowledge as to the Medicaid eligibility process, persons who find themselves in a skilled nursing facility may have no background information as to these processes whatsoever. They may have some vague notions about what Medicaid is, and oftentimes their understanding is not close to being correct. I am careful when throwing out terms that I use on a day-to-day basis to keep in mind that all of this information may be completely new, foreign and confusing to the resident or legal agent. So, for example, when I refer to “patient liability”, I don’t assume that they know what this means, but rather, explain what it is in a simple, easy-to-understand way.

DO YOU HAVE QUESTIONS?

Throughout the conversation, I will ask them if they have questions regarding the process. This can be very useful as the resident or legal agent will oftentimes bring up some concern that may in fact have an impact on the Medicaid eligibility process. For example, they will ask: what about the mortgage that is due on the community property, what about the life insurance policy that was signed over to the funeral home, what about the vehicle that is in their name? All of this is helpful to know sooner rather than later. This is why a dialogue is so useful.

If by the end of the conversation they indicate they will cooperate (and they usually do), I will confirm the next steps, make sure they have my contact information, and note that I want to keep them informed and included in the process.

WHAT IF THEY STILL REFUSE TO COOPERATE?

It does happen. If the resident has capacity, it can be very challenging as they are able to be their own decision-maker and if they refuse to cooperate, little can be done to change that. In these situations, I may note to the resident that the facility will explore all its options available to them. These may include discharge, litigation, or other options.

TIME IS OF THE ESSENCE

One of the most important considerations to keep in mind is that it is generally better to act sooner rather than later where a provider is faced with a lack of cooperation by their resident or legal agent in securing Medicaid benefits.