Medicaid is a health insurance program for low-income Americans. It serves people of all ages and allows those who were previously uninsured access to much-needed medical care.
While Medicaid is a federal program, it is administered by states. That means the exact rules for eligibility can vary throughout the country, making the system difficult to navigate.
If you believe you are eligible for Medicaid coverage but are unsure of the rules or you are denied funding, speaking to a Medicaid lawyer is often your best option.
Why would someone need a Medicaid lawyer?
Depending on your state, Medicaid can cover anything from routine annual care visits to long-term assistance that allows the elderly and disabled to afford specialized procedures or even the kind of daily care that allows them to remain in their homes. It can even pay for the caregiving services provided by friends and certain family members.
However, Medicaid’s rules can be very complex. If you move to a new state, the services you previously had covered by Medicaid may no longer even be available to you. Because it can be such an intricate system to navigate, Medicaid lawyers are available to assist people who need help applying for coverage, planning their care, as well as those who have been denied their benefits.
Even if you are eligible for Medicaid, you may find that the state can still deny coverage to you or your eligible loved one. Sometimes it’s unclear why this is happening. Having Medicaid decline to pay a bill or approve a procedure or care plan can be a very stressful event, and the idea of dealing with the state bureaucracy can be overwhelming, particularly if you are already sick, disabled, or caring for a loved one.
Some of the most common reasons for the denial of Medicaid or specific benefits include:
- Your application is incomplete
- You’ve waited too long to file a claim (you usually have 60-90 days, but it will differ by state)
- You’ve failed to respond to follow-up inquiries in a timely manner
- Your income or assets do not meet the state’s guidelines for coverage
- Your medical documentation is not comprehensive enough to prove you are disabled
- Your physician does not submit documentation in time or is responsible for a coding error
What Medicaid lawyers do
Medicaid lawyers can be most helpful in situations in which you need to understand what’s going on if your coverage was denied. But, perhaps more importantly, they can help you fight the decision when it’s appropriate. If you have a legal right to Medicaid benefits but aren’t receiving them, they will help you file an appeal.
Medicaid lawyers can also help when an application is stalled in the system, slowing down your payment or access to care. They can even keep track of where you are in the application process and make inquiries on your behalf so that state agencies review applications in a more timely fashion.
You may need the services of a Medicaid lawyer if you decide to schedule a fair hearing. The fair hearing process is your right to go before an Administrative Law Judge (ALJ) if you are denied your legal Medicaid benefits. A fair hearing process is scheduled if one of the following things happen:
- You are denied Medicaid coverage altogether even though you are eligible
- If Medicaid suspends, reduces, or denies coverage for a specific service that you should have access to
- Your state Medicaid office does not act in a timely fashion to make a decision about your eligibility or service coverage
Hiring a Medicaid lawyer for the fair hearing process
If you decide to appeal Medicaid’s decision, having a Medicaid lawyer to represent you during a fair hearing process can take the pressure off of you to know all of the specific state rules. They can also advise you whether or not scheduling a hearing is even appropriate.
If you are eligible for Medicaid services but are denied coverage, you have just 60-90 days (depending on your state) from the time you receive the notice to schedule a fair hearing. After this time has elapsed days, you are no longer eligible to fight the decision, so having a Medicaid lawyer to help you navigate this process can make all the difference.
In addition, you will likely need to provide evidence of eligibility to the judge. This can include gathering documentation from your personal records as well as from physicians. Knowing what information you need, how to secure it, and how to present it in court is another reason that having a Medicaid lawyer will make it easier to effectively fight for your right to appropriate coverage. Your hearing may last roughly an hour, so having the correct evidence or witnesses to help plead your case is important.
A Medicaid lawyer can also help you understand what do to while you are waiting for your hearing, including what benefits you can still apply for, who you can talk to, and what forms need to be filled out along the way. Since the judge’s decision is not handed down immediately but rather arrives by mail a few weeks after the hearing, a lawyer can be helpful in keeping track of timelines.
If a judge rules against you at a fair hearing process, your fight may not be over. If you and your lawyer are convinced you are entitled to Medicaid coverage, you can appeal the fair hearing decision as well. Should you need to appeal a denial a second time, your Medicaid lawyer can help guide you through that process.
Fighting a decision handed down by your state Medicaid authority isn’t the only reason to consider hiring a lawyer. Medicaid lawyers can also help with long-term planning, especially when it comes to navigating asset management.
The rules for Medicaid eligibility can be complex when it comes to not only your income but valuing your assets (such as your home or car). Your spouse’s assets are considered in the eligibility equation as well. However, if you offload assets in order to qualify for Medicaid, you may be penalized and barred from receiving coverage in the near future. A Medicaid lawyer can help you estimate your total assets and navigate the reporting process in order to avoid these problems.
While Medicaid does not cover the cost of assisted living facilities, it does allow elderly and disabled Americans the opportunity to remain in their homes and communities for much longer by paying for these in-home caregivers. Medicaid will even for the caregiving services of friends and certain family members. But it’s helpful to consult an attorney on the rules for compensating these caregivers. Hiring a caregiver can help save both you and Medicaid a great deal of money since the cost of rehabilitation clinics and other short-term care facilities are so high, but you have to ensure that you’re choosing the right person in order to qualify for this benefit.
Of course, to understand all of the benefits Medicaid has to offer, it’s helpful to have a skilled lawyer advise you on your options. This is especially true since one state may cover a service that another does not.
How much does a Medicaid lawyer cost?
Hiring a lawyer gives you a clear advantage when it comes to appealing care decisions or moving along your request in the bureaucratic system. But Medicaid attorneys can also be quite expensive, especially for those who are already living below the poverty line.
The cost of hiring a Medicaid lawyer will vary based on your state as well as the services you’re asking them to provide. But you can expect to pay around $300 to $600 an hour for their services. The average cost of hiring an attorney for a court hearing can range from $3500 and $15,000. Of course, this may pale in comparison to the amount you would pay for medical services if a bill is rejected by Medicaid.
Best Medicaid lawyers in Pennsylvania
If you live in the state of Pennsylvania and need the services of a Medicaid lawyer, you can find help by calling one of these experienced attorneys:
1372 N. Susquehanna Trail
Suite 130, The Courtyard Offices
Selinsgrove, PA 17870
Dennis L. Abramson Esq.
111 Presidential Blvd #245, Bala Cynwyd, PA 19004
1801 Market St, Philadelphia, PA 19103
Cipriani & Werner
450 Sentry Parkway
Blue Bell, PA 19422
Lewis Brisbois Bisgaard & Smith
550 E. Swedesford Rd.
Wayne, PA 19087
25 S. Church Street
West Chester, PA 19382
Free Medicaid representation in Pennsylvania
If you cannot afford to hire a Medicaid lawyer in Pennsylvania, you may be eligible for the services of the Pennsylvania Health Law Project (PHLP) or other pro bono services from legal aid clinics.
PHLP is a 501(c)(3) non-profit organization that provides free legal representation to Pennsylvania residents fighting to keep Medicaid coverage and services. To see if you are eligible for their services, you can call 1-800-274-3258.