Retroactive Medicaid Benefits Secured via PRUCOL Application

FACTS:  An individual in the U.S. legally on a “Religious Worker” visa unexpectedly fell ill and required nursing home care.  The facility promptly filed a Medicaid application with the local social services district requesting an April 2019 pick-up date and supplying a copy of the resident’s passport, visa and other documents proving her lawful residence in the United States.  The Department of Social Services (“DSS”) determined that the resident could not qualify for institutional Medicaid benefits because she had overstayed her visa – meaning that she was “undocumented” according to DSS, and therefore ineligible for Medicaid benefits.  The facility later secured missing pages to the resident’s passport containing evidence of a more recent entry into the U.S., proving that she had not overstayed her visa on the date that the Medicaid application was filed. However, DSS was still not satisfied. 

DSS then claimed that the type of visa the resident had did make her eligible for Medicaid institutional benefits. The facility then retained Cona Elder Law to intervene, now months after the application had been filed. Cona Elder Law promptly filed an Application to Adjust Status (“PRUCOL” application) with the U.S. Department of Homeland Security, establishing the resident’s PRUCOL status as of July 30, 2019. 

DSS issued a determination approving Medicaid benefits with an effective coverage date of July 30, 2019 based on the filing of the PRUCOL application.  However, this was in error as Medicaid should have been authorized as of the requested pick-up date of April 2019. When DSS failed to revise its determination, Cona Elder Law escalated the case to a Fair Hearing.  At the Fair Hearing, Cona Elder Law argued that guidance published by the Department of Health made clear that the documentation supplied to DSS entitled the resident to institutional Medicaid benefits as of the originally requested pick-up date. 

In a strongly worded decision, the Department of Health reversed the agency’s determination and directed DSS to authorize institutional Medicaid coverage to the resident, with coverage effective as of the requested pick-up date of April 2019.  Additionally, the language included in the Decision After Fair Hearing will serve as important precedent in arguing that similarly situated temporary non-immigrants in New York State are entitled to PRUCOL status and institutional Medicaid benefits in New York State in future cases.

RESULTS: Medicaid Benefits secured from the original pick-up date to the present and ongoing.

Cona Elder Law Attorney:  This case was successfully handled by Dana Walsh Sivak, Esq.