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PRUCOL: Qualifying Residents Without Legal Immigration Status for Institutional Medicaid Benefits

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Healthcare facilities are often unaware until a resident enters its doors that the individual may have a problematic immigration status that can affect their institutional Medicaid eligibility.  Luckily, by filing an application to resolve a resident’s immigration status and/or establishing “PRUCOL” status (i.e. “Permanently Residing in the U.S. Under the Color of Law”), a resident can quickly become Medicaid-eligible, as long as he or she is otherwise eligible for benefits.

Often, the filing of a PRUCOL application is enough to secure institutional Medicaid benefits eligibility.  Cona Elder Law has been successful in securing ongoing benefits coverage for many residents at the initial Medicaid application stage, followed by careful monitoring and management of the PRUCOL application, particularly at the time of recertification to ensure continued benefits. Since some undocumented residents lack any source of income (including Social Security, for which they are typically ineligible), the facility may receive all of its reimbursement for care provided to those residents from the Medicaid program (i.e. a zero NAMI budget), making the eligibility determination even more crucial for ensuring payment is received.

Other times, however, even when all of the proper steps are followed and the resident indisputably has PRUCOL status, the Medicaid agency may be unwilling to authorize coverage, or simply lack the experience in authorizing coverage in these types of cases.  In these instances, it can be advantageous to establish a dialogue with the county to help them work through these issues. If that effort fails, it may be necessary to address the refusal to authorize coverage at a Fair Hearing.  Thankfully, Cona Elder Law has secured favorable outcomes at several Fair Hearings focusing on immigration-related issues.

In one case, when a Medicaid application was denied for lack of proof of citizenship resulting in a $300,000 balance due to the facility, Cona Elder Law quickly established the resident’s PRUCOL status by filing an immigration application and, after a successful Fair Hearing, secured 24 months of retroactive coverage and ongoing benefits for the resident.  In another case, where the county refused to authorize coverage even though the evidence of the resident’s PRUCOL status was incontrovertible, Cona Elder Law escalated the matter to a Fair Hearing and convinced the county to authorize coverage voluntarily prior to a decision being issued. Most recently, Cona Elder Law’s hard fought Fair Hearing victory resulted in a decision that could be used as precedent to expand Medicaid eligibility to other non-U.S. citizens in the future, where the county was chastised for adopting an anti-immigrant position in some of its arguments, and full retroactive Medicaid benefits were authorized as of the requested pick-up date based on the strength of Cona Elder Law’s arguments.  (For more information regarding these and other Cona Elder Law Case Victories, please click here.

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