The Intersection of Guardianships and Medicaid: Securing Medicaid Benefits When a Resident Lacks Capacity

Cona Elder Law Secures over $460,000 in Medicaid Reimbursement.

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A.P., a resident of a skilled nursing facility since 2009, had diminished capacity and was unable to assist the facility with an application for Medicaid benefits. As the unpaid balance was growing, Cona Elder Law petitioned the Court for the appointment of a Guardian whose main role was to secure all required information and documentation to complete an application for Medicaid benefits. Upon filing the court petition, a Medicaid application was filed concurrently with proof that a Guardianship proceeding had been commenced. Based on the pending Guardianship, conditional approval was granted and Medicaid benefits were authorized.

When the conditional approval expired, the Medicaid agency sent a Notice of Decision discontinuing Medicaid benefits only to the incapacitated resident. Notice was not provided to the facility or to the Guardian. Cona Elder Law challenged the Notice in that it was insufficient under the law and also argued that the statute of limitations to request a Fair Hearing was tolled. Cona Elder Law negotiated a settlement with the HRA Office of Legal Affairs and secured Medicaid benefits retroactive to 2009 for a total reimbursement of $460,000 to the facility -- without having to go back to court or even attend a Fair Hearing.