Innovative Strategy Yields $161,500 in Cost-Effective Medicaid Settlement

Facts: A Skilled Nursing Facility Resident’s Medicaid application was denied because his spouse made asset transfers totaling over $500,000.

Upon the referral of this matter to Cona Elder Law, we immediately contacted the attorney for the resident and spouse and demanded payment in full, advising that if same was not forthcoming, we would file a claim in Court by the end of the day. The attorney advised that she felt her client had a viable argument at Fair Hearing and that she would not remit payment without first exercising the right to a hearing and appeal.

Having a robust private-client Elder Law practice, Cona Elder Law understood the need for the resident’s attorney to attend the Fair Hearing, fight for her client, and secure the result she was hired to achieve. As such, we found a creative solution that worked for all parties, but, most importantly, one that secured our health care facility client’s bottom line.

We negotiated an agreement with the resident’s attorney that resulted in the payment of $125,000 to the SNF and also permitted the resident’s attorney to pursue a Fair Hearing.

The stipulation of settlement provided the community spouse to immediately remit payment of the full private pay balance due to the SNF, which amount totaled $125,000, to her attorney to be held in the attorney’s escrow account pending her attendance at a Fair Hearing and the issuance of a decision regarding the application for Medicaid benefits.

The terms of the stipulation dictated that for every month until such time as the Fair Hearing was held, the community spouse would also be  obligated to remit payment to her attorney of the private pay balance due for the month, also to be held in escrow.

In addition, in order to ensure the expeditious resolution of this matter, the terms of the stipulation required the attorney to attend the first scheduled Fair Hearing. In the event the attorney or her client sought an adjournment, the private pay monies in the escrow account would immediately be released to the SNF and the community spouse would be obligated to continue to remit private payment each month thereafter until such time as Institutional Medicaid benefits were secured.

Not only did the clients sign this Stipulation of settlement, but Cona Elder Law required their attorney to sign the stipulation as well in order to guarantee her obligations and compliance with these terms.

Of course, to be fair and to facilitate this advantageous settlement, the stipulation held that if at any point in time institutional Medicaid benefits were secured for the resident for a period during which private pay monies were received, the SNF would provide a dollar for dollar return upon its receipt of payment from Medicaid.    

Understanding the mentality of private clients, Cona Elder Law achieved this settlement in a matter of days that not only resulted in payment of the full balance due, but provided total protection to the SNF that the settlement monies and on-going monthly balance due was 100% secured. Rather than taking a gamble in drawn-out litigation, not to mention legal fees incurred during that time, Cona Elder Law once again provided cost-effective, superior results with our creative advocacy and invocative strategies.

Result: $125,000 representing 19 months of retroactive Medicaid coverage secured immediately plus NAMI paid in the amount of $36,500. SNF paid in full.

Cona Elder Law Attorney: This case was successfully handled by Ken Kern, Esq.