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Medicaid Denial Reasons and the Appeals Process

Qualified Medicaid Denial and Appeal Process Lawyer Serving Green Bay, Wisconsin

Medicaid is an excellent approach to ensure that you and your family have access to dependable health care. To qualify, you must meet tight income and asset restrictions that vary from year to year. If your Medicaid application has been rejected, the qualified Green Bay Medicaid denial and appeal process lawyer at Silver Divorce Wisconsin will guide you or a loved one through the Medicaid appeals process and assist you in developing a strategy to qualify for benefits.


Remember that if your Wisconsin Medicaid application is denied, you have the option to submit an appeal. It is not uncommon for those who should qualify for coverage to be denied it. At Silver Divorce Wisconsin, we assist Green Bay-area and statewide Wisconsin residents in understanding Medicaid eligibility and the steps necessary to get Medicaid coverage.

Why Do You Need a Medicaid Appeal Process Lawyer in Wisconsin?

When you’ve been denied Medicaid coverage, it can feel like the end of the world. After all, Medicaid is supposed to be there for people who need help paying for medical care. If you’ve been denied coverage, it means that you’ll have to pay for your care out of pocket – and that can be very expensive.

That’s why it’s so important to have our skilled Medicaid appeal process lawyer on your side. We know the ins and outs of the system can help you navigate the appeals process and give you a better chance of getting the coverage you need. Here are some of the benefits of hiring our Medicaid denial and appeal process lawyer:

  • We know the ins and outs of the system and can help you file an appeal quickly and efficiently.
  • We can represent you in court and argue your case before a judge.
  • We can advise you on what steps to take next and help you prepare for your hearing.
  • We will fight for your rights and make sure that your voice is heard.
  • We can provide emotional support during difficult times.
  • We have experience dealing with insurance companies and know how to get results.
  • Our skilled Green Bay Medicaid denial and appeal process lawyer charges reasonable fees, often less than what you would pay for other legal services.
  • Hiring our Medicaid appeal process lawyer is often the best way to ensure that your case is handled fairly and that you get the coverage you deserve.
  • You have nothing to lose by hiring us, and everything to gain.

If you’ve been denied Medicaid coverage, don’t give up hope. Contact our competent Green Bay Medicaid appeal process lawyer today and get the help you need to get the coverage you deserve.

What Constitutes Medicaid?

Medicaid is a program that offers extremely low-cost or free health care to certain low-income adults and children. Medicaid is jointly funded by the federal and state governments, and each state administers its own Medicaid program. Some states have given the Medicaid program a new name, such as Medi-Cal in California and MassHealth in Massachusetts.

Who is Eligible to Receive Medicaid Program?

medicaid appeal process lawyerMedicaid eligibility requirements vary from state to state, although there are certain commonalities. To qualify for Medicaid, you must generally have a low income and few assets. However, not all low-income individuals with little assets are eligible for the program. There are various kinds of Medicaid eligibility, including disability, pregnancy, and age over 65.

Medicaid eligibility for individuals with disabilities is contingent on meeting income and asset restrictions. SSI recipients automatically qualify for Medicaid in the majority of states. Medicaid is available to pregnant women who fulfill the income and asset criteria. Medicaid-eligible women are automatically insured for one year following the birth of their children. Many states grant Medicaid coverage to pregnant women with higher incomes and assets than the federal guidelines allow.

Women with breast or cervical cancer can receive treatment via a Medicaid program designed specifically for these conditions. Numerous states provide this coverage to women with greater incomes. About three-quarters of states additionally provide Medicaid eligibility for persons who do not meet Medicaid’s conventional income and resource requirements but are “medically needy.” A person is medically in need if his or her medical expenditures are so severe that they lower his or her income or assets to qualifying levels.

What Medical Treatments or Services Does Medicaid Expect to Be Paid For?

Each state can select which services will be covered by its Medicaid program, although some treatments must be covered. Mandatory covered services include inpatient and outpatient hospital bills, medications, lab costs, long-term care services, transportation to medical appointments, and pediatric eye and dental care.

In addition to the obligatory covered treatments, some states have decided to give Medicaid coverage for items like spectacles, hearing aids, physical therapy, mental health services, and hospice care. Even though Medicaid may pay for certain treatments, it might be difficult for a Medicaid client to obtain them if no provider in the region takes Medicaid as payment. 

In many rural regions of the country, for instance, there are no dentists that take Medicaid, therefore Medicaid-eligible children may not have access to dental treatment. Medicaid recipients must demonstrate that a particular service is medically essential for Medicaid to pay for it. Each state has defined medical necessity as it applies to its Medicaid program, as there is no federal definition. 

The medical necessity requirement generally prohibits Medicaid recipients from receiving coverage for elective treatments and procedures.


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How Do Recipients Receive Their Medicaid Services?

Many Medicaid beneficiaries receive treatment through managed care organizations, which are commercial corporations hired by states to supply Medicaid-compliant medical services. Other Medicaid recipients continue to receive “fee for service” Medicaid, in which the state pays a fee to the medical provider for the Medicaid recipient’s care.

Medicaid is intended to be affordable for low-income individuals in all states; hence, services are often offered at no cost.

What Are the Reasons for Medicaid Denial?

Medicaid enrollment may be tricky. While applications may appear basic, several hidden traps might result in Medicaid benefits being rejected or lengthy approval delays.

Income Exceeds the Set Limitation

In the majority of states, if your total income exceeds a certain threshold, you will not be eligible for Medicaid. Individual states impose stringent limitations on the amount of money or income required for Medicaid eligibility.

Insufficient Documentation

Approximately 75% of Medicaid application denials are attributable to the absence of required documents. Incomplete applications are subject to rejection. Occasionally, you may be required to provide additional documentation. Denial will also come from failure to supply the relevant information in a timely and full manner.

Required Specific Details

Included among the documents requested by Medicaid are bank statements and tax returns. Remember that when Medicaid reviews your application, they are trying to ensure that you qualify for the program and do not have an excessive amount of money or valuable assets.

While some states use electronic asset verification systems that obtain information from banks and financial institutions to determine Medicaid eligibility, most states rely on your submission of documents. Failing to have a full application or to reply to requests for extra information will lead to a refusal.

Misplaced Applications and Supporting Documents 

People processing applications, from postal service personnel to state Medicaid examiners, sometimes lose portions of applications, and papers, or misread what was submitted. This is a more prevalent basis for denials than you might imagine.

The individuals examining your applications are fallible humans who may make mistakes. It is likely that certain attachments are lost or that supporting documentation cannot be tracked back to the original application when applications are passed from one department to another.

Keep a Record of Your Documents

It is essential that you transmit actual copies of your application and supporting papers in a way that permits shipping tracking. It is recommended that you include a professional cover letter with your application that lists all of the documents. The more structured and precise your proposal is, the more chance you have of it remaining altogether.

Additionally, if you are going to clip documents together, be sure to use binder clips that securely hold them. Finally, always send duplicates of every correspondence. This implies that even if you are shipping a 2-inch stack of documents, you must ensure that you have duplicates of everything.

Moved Assets

The applicant moved assets to qualify for Medicaid assistance, which is another ground for denial. The restrictions regulating assets and asset transfers are highly tight. Even if you transferred over $500 in assets to a family member as a significant gift, the majority of states would impose required ineligibility periods for each dollar amount transferred.

Five Year Retrospective

Many people typically state that the government allows donations of up to $14,000 which is right for taxes, but not so for Medicaid. Medicaid often examines your financial records from the previous five years to ensure that no asset transfers were undertaken to qualify for Medicaid.

Rapid Responses

Medicaid may have further questions or requests upon receipt of your application. The government normally expresses demands to the applicant in writing. The ten-day response period for the majority of letters begins on the date of the letter, not the day it was received.

Consequently, it is essential to be organized and vigilant during the application process. If you get a request for further information, you should react quickly and trace the delivery of any supporting evidence.

Utilize a Checklist

Medicaid is an absolute requirement for many individuals, and denial of coverage can exacerbate an already severe situation. It is essential to avoid actions that might compromise or postpone your application. Remember that the most common cause for denial is missing papers, so create a checklist and make copies of everything.

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What is the Denial Notice?

If your state Medicaid agency declined your application for Medicaid, you have the option to appeal the rejection. Your state agency will handle the appeal, but it must adhere to federal Medicaid appeal regulations. You might be refused Medicaid if you had too much money or assets, or if your state Medicaid agency did not believe you were handicapped if you applied based on disability. When a state Medicaid agency denies a request for assistance, a formal denial notice must be sent.

When Will You Receive the Notice of Refusal?

States are required to adhere to federal timeframes for Medicaid application determinations. States have the following timeframe to issue you a notice of denial:

  • If you are applying for Medicaid based on a disability, you must do it within 90 days of your application date.
  • If you apply for Medicaid on another basis, you must do it within 45 days after the application date.

Within such timeframes, you should get a written notification of the decision.

How Can You Appeal If Your Medicaid Application is Denied?

Some states require Medicaid beneficiaries to submit their appeal petitions in writing, while others do not. To discover your state’s rules, read your notice carefully. Even if you are not required to file a written notice, you should nonetheless do so. You can draft a straightforward appeal letter.

If possible, submit your request in person at your state Medicaid agency’s local office and have it postmarked to show that it was received by the deadline. You want to avoid establishing that your appeal was submitted on time or justify a late appeal.

Medicaid Appeal Proceedings

Once your appeal is scheduled for a hearing, you must attend (in person or by phone, depending on the state’s regulations) or risk having your appeal dismissed. If your appeal is denied due to your absence from the hearing, you must demonstrate “good cause” (a reasonable reason for missing the hearing) to have the hearing reopened. 

It might be tough to establish that you have a good cause. It is insufficient to argue that you forgot the date or lost the notification. Your state Medicaid agency will provide you with information regarding the hearing procedure. In certain areas, the state Medicaid agency conducts hearings, but other states have independent hearings agencies or utilize the court system. 

After proper notice, hearings must be held at a reasonable time, day, and location. One or more hearing officers (judges) may conduct hearings, so long as they are impartial and are not directly involved in the initial decision to reject your benefits. Hearing officers can work for the state’s Medicaid agency even if the hearing is at a separate agency.

Getting Ready for the Hearing

Before the hearing, federal Medicaid regulations require states to grant Medicaid applicants access to their files and all the documents upon which the agency relied in denying your Medicaid coverage.

It might be beneficial to write down the points you wish to make to the judge or hearing officer so that you do not forget them during the hearing. In addition, you have the opportunity to present your witnesses at the hearing and to question any of the agency’s witnesses.

You may choose to retain legal representation. You can call your local legal aid agency to determine if they assist clients in Medicaid appeals, or you can reach out to our seasoned Green Bay Medicaid denial and appeal process lawyer. Additionally, federal Medicaid regulations let you utilize a family member, friend, or any other representative of your choosing to assist you with your appeal, or you can represent yourself.

Medical Assessments

If your Medicaid application was denied because the state Medicaid agency believed you were not disabled, the hearing officer may decide to order you to undergo a second medical exam. If the hearing officer orders you to have a medical examination, you will lose your appeal. The state will pay for any medical checkups or testing that it requests.

After the Hearing

You will get written notification of the decision made by the hearing officer. If you lose your hearing, the notification will include the appeals process. Depending on the state’s particular procedures, at your next appeal, you may not get another chance to testify and bring witnesses (at what’s known as an evidentiary hearing).

You may instead be confined to submitting written arguments about the evidence presented during the initial appeal hearing. Check your refusal letter carefully to determine the state’s appeal procedures.

Retroactive Application of Medicaid Coverage

If you win your appeal and qualify for Medicaid, the state Medicaid agency will retroactively apply your coverage to the day you became eligible. In most cases, this will be the date you submitted your Medicaid application. Keep track of all medical expenses incurred after the date of your Medicaid application so that you can report them to the state Medicaid agency when you become eligible for benefits.

How Can You Avoid Medicaid Appeals?

People from all walks of life may qualify for Medicaid assistance, but certain individuals are more likely to benefit from the advice of our Green Bay Medicaid denial and appeal process lawyer. For example:

  • Adults who may require long-term care may incur substantial expenses. Planning for long-term care can help minimize or at least reduce these expenditures by assuring Medicaid eligibility when it is required.
  • Families of those with special needs face difficulties in preserving assets while maintaining eligibility for government benefits for their loved ones. The use of estate planning mechanisms, such as various forms of trusts, can help achieve these objectives.

There is no one-size-fits-all answer, and the possibilities are state-specific. Therefore, it is essential to discuss your circumstances with our seasoned Medicaid appeal process lawyer.

How Can Our Green Bay Medicaid Denial and Appeal Process Lawyer Help?

If you are concerned about your Medicaid eligibility, you should seek legal counsel. Our knowledgeable Green Bay Medicaid denial and appeal process lawyer can prevent you from squandering down your assets excessively, advise you on how to manage your funds to maintain eligibility, and complete the application on your behalf.

There is a built-in appeals procedure that involves administrative hearings and judicial actions to protect the rights of vulnerable seniors whose Medicaid applications are originally refused. We have extensive knowledge of elder law and can defend your rights if your application is rejected.

Pre- and post-retirement clients receive our individualized legal services, including Medicaid preparation for those worried about the expense of nursing facility care. Call us now to find out how Silver Divorce Wisconsin might assist you in obtaining the services you deserve.

Schedule an Appointment With Our Green Bay Skilled Medicaid Appeal Process Lawyer

Our skilled Medicaid appeal process lawyer at Silver Divorce Wisconsin can assist you with the Medicaid application process. Our seasoned practitioners keep ahead of legislative changes that may influence your eligibility, and we are unafraid to challenge an unjust refusal.

Suppose you are just beginning the Medicaid application process or believe you or a loved one may require Medicaid in the future. In that case, we can also assist you with the preparation and the application procedure. Call us immediately, whether you live in Green Bay or anywhere else in Wisconsin, to find out how our Medicaid denial and appeal process lawyer can assist you with your Medicaid appeal.

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