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Assisted Living Medicaid is Still Not Retroactive (Part 2)

                Last week I was telling you about an important difference between assisted living Medicaid and nursing home Medicaid.  I explained this to my client but she heard – or thought she heard – something different from the facility.

                I had said that ALF Medicaid is not retroactive, meaning if I apply for Medicaid in June and am financially eligible for June but Medicaid doesn’t approve the application till December I won’t get Medicaid to start paying until December.  The 5 month gap is something I or my family must pay at the facility’s private pay rate.

                My client called me a few weeks later to tell me that the facility said there is “gap coverage” for this period.  That didn’t sound right to me so I called the facility.  Sure enough there was a misunderstanding.  The facility representative was talking about something entirely different.  Let me explain.

                A few years ago New Jersey Medicaid went to managed care.  After Medicaid is approved it can take a few months until managed care kicks in – until the MCO starts paying.  During that “gap” period the State will cover the cost.  As is common with Medicaid, how everything works is so complicated and confusing that familys think they understand what they are being told or what they read but are entirely incorrect.  This is a perfect example.

                So, the moral of this story is “things aren’t always what they appear to be”.  It is best to seek advice from a knowledgeable professional experienced in Medicaid matters.  And while we are on the subject, you may be wondering why is it that nursing home Medicaid is retroactive and ALF Medicaid is not.  It’s really unfair.

                No question it is unfair but a lot of things about Medicaid are unfair.  ALF Medicaid is what is called a waiver program.  States are not obligated to provide coverage under federal Medicaid regulations.  They can choose to offer it – or not – at their option.  Some of the rules, therefore are different.  The start date for waiver coverage is as of the date of service plan approval.   That is contrary to Medicaid’s general rule that coverage can begin as much as 3 months before the application is filed (provided the applicant has met all eligibility requirements for that period).

                Interestingly, a case was brought last year in federal court in Ohio challenging this policy of no retroactive coverage.    The District Court held that there should be retroactive coverage for waiver programs such as ALF Medicaid.  However, Ohio appealed the decision and the Sixth Circuit Court of Appeals reversed the lower court’s decision so the coverage gap remains in place.  So, until further notice ALF Medicaid is still NOT retroactive.