The Needle that Does Not Move: Navigating the Pitfalls of Medicaid Look-Back Periods for Community Medicaid Recipients

Many in the nursing home industry are familiar with the lookback period used in evaluating Institutional Medicaid benefit applications. Broadly speaking, any transfers of assets made within five (5) years of the date of the application may result in the imposition of a penalty period. In 2015, the Department of Health issued GIS 15 MA/07, outlining how the start date for that lookback period should be determined for both new Medicaid applicants and existing community Medicaid recipients. However, while this regulatory guidance was issued nearly a decade ago, it has only recently been implemented, due in large part to the “continuous coverage” requirement in effect throughout the pandemic. As a result, many long-term care residents seeking to convert community Medicaid benefits to Institutional benefits must now navigate a regulatory minefield, often with disastrous consequences.

According to GIS 15 MA/07, for new Medicaid applicants, the lookback period is measured from the date of the application. For community Medicaid recipients seeking to convert their coverage to Institutional Medicaid, the look-back period is 60 months (or 5 years) measured from the month of institutionalization. While these residents may request an increase in coverage to be applied up to three months prior to the date of the request, the look-back period remains 60 months from the date of institutionalization, not the date the increase in coverage is made. For example, if a resident seeking to convert community Medicaid benefits has transferred assets within 60 months of the month he or she was admitted to a skilled nursing facility, a penalty period may be assessed for that transfer, regardless of when the conversion application was submitted. The rigid application of this regulatory guidance can lead to hefty penalty periods or lapses in coverage.

Cona Elder Law’s experienced attorneys continue to monitor the most recent developments regarding this legislation as well as other important legal matters concerning the skilled nursing facility, assisted living, and CCRC industry.  Contact us at 631.390.5000 to learn more about how our firm can help your facility preserve your bottom line and ensure your ability to continue to provide quality services to your nursing home residents.

This article was originally published on LeadingAge New York.