For skilled nursing facility residents applying for long-term care Medicaid benefits, under federal regulation, all state agencies are required to issue an eligibility determination on the application within 45 days of the date of the application (90 days for applicants who apply on the basis of a disability) (see 42 CFR 435.912). State agencies vary widely in how diligent they are in keeping to these timeliness standards.
Recently, this issue came to the forefront due to action taken by the Center for Medicare & Medicaid Services (“CMS”) in addressing Missouri’s significant, ongoing delays in meeting these timeliness standards. On May 22, 2024, CMS notified Missouri of a mandatory action plan it is requiring due to Missouri’s ongoing delays in processing Medicaid applications. CMS developed a mitigation plan with the Missouri Department of Social Services in 2022 to address the backlog of pending Medicaid applications. Now, after the application backlog numbers have started to increase again, CMS is requiring that Missouri comply with detailed reporting requirements to CMS and has notified the Missouri Department of Social Services that if it does not comply with the mandatory reporting requirements, it may be subject to a formal compliance action.
A copy of the CMS letter can be found here: https://www.documentcloud.org/documents/24762403-missouri_application_timeliness_review_letter_signed_52224
What all state agencies understand is that CMS could ultimately restrict federal funding for the state’s Medicaid program, which would create profound problems for the state. These timeliness issues in the processing of Medicaid applications exist in many states, not just Missouri. And these delays in processing Medicaid applications can cause serious issues. For example, if a Medicaid application is denied because the agency discovered a life insurance policy in its asset verification system that places the applicant over the resource eligibility limits, having a denial based on such (along with disclosure of the asset) can allow the applicant to address the issue and spend such down sooner rather than waiting for an extended period to begin the spend down process. Delays in the processing of applications can have prejudicial effects on the applicants, and ultimately, on skilled nursing facilities.
OPTIONS FOR FACILITIES TO ADDRESS DELAYS IN PROCESSING:
Appeal:
What can applicants do if they are facing such delay issues? Do applicants and skilled nursing facility business offices have to wait until CMS takes up their own state’s delay issues? The answer, fortunately, is that you do not have to wait until CMS takes up the issue on a state-wide basis. In all states there are appeal rights and appeals are not just limited to when the agency issues a notice that the applicant does not agree with. Applicants can also appeal the inaction of the agency, and certainly failure of the agency to meet the very specific timeliness standards mandated under federal regulation qualifies as a valid basis to initiate an appeal.
Consolidated Appeal:
For skilled nursing facilities that are facing severe, widespread processing issues, submitting a consolidated appeal can be very effective. Filing an appeal for all applicants in the nursing facility, together, may act to get the attention of the agency. Agencies do not want to get a letter from CMS such as Missouri received on May 22nd. Putting the agency on notice as to the extent of its delay issues can save the facility time and may assist in having the issues addressed collectively, quickly.
Getting CMS involved:
If the delays are widespread and ongoing, certainly the issue can be presented to CMS, requesting that it take up the issue with the state directly. In reaching out to CMS, it is best to have specific data and information to present to CMS which details the delays in processing.
