Here’s a hint: It’s lower than you can even imagine.
If there’s a moral to this story, I’ll save you the suspense and tell it to you now: A MassHealth application is something that you should hire an attorney to do, and not something you should try to do on your own. While I have felt that way for many years, a recent case showed me, in even bigger, brighter letters, how true it is.
I’ll also tell you the end of the story before the beginning. We won this case and secured a great victory for our client. Because of our efforts, MassHealth has to write a check for roughly $150,000 for our client’s nursing home care. I have no doubt whatsoever that without us, the client would not have won this case, could not have won this case, and would have been stuck with having to sell his home in order to pay the $150,000 owed to the nursing home that MassHealth was refusing to pay.
The story demonstrates that MassHealth will really stop at nothing delay or deny your claim (and usually, they try and do both). There's no doubt about it that the system is broken. People that have worked and saved for their entire lives are expected to spend their life savings on long-term care when people that have not saved a dime their entire lives and spent every penny they ever made can receive a quick and easy approval for long-term care whenever they want. The system is backwards and it punishes the wrong people.
I understand that it is the caseworker’s job to only approve individuals that meet the guidelines. And some of the caseworkers are great. But what I will never understand is when they try so hard to deny someone that really is entitled to benefits. It’s baffling to me.
To illustrate that, I want to tell you a story about a client of ours named Jim.
Jim was a wartime veteran, a widower, and he was suffering from health problems that required long-term care. He had to go into a nursing home last year. Jim owns a house and not much else. His life savings was sunk into paying off his home, and therefore his assets consisted of just the equity in his house. He had very little savings.
Jim's son came to us to talk about MassHealth long-term care benefits. We reviewed the case and expected that we could obtain approval relatively easily for Jim for Medicaid MassHealth, where they would pay the majority of his nursing home bills.
Now, when I say relatively easy approval, I mean that in comparison to many of the other cases that we see. It’s something that is relatively easy to us because we do it every day but is still something that would be exceedingly difficult if Jim's son had tried to do this on his own. Jim moved into the nursing home and we advised the nursing home that we were applying for benefits and that we expected to obtain approval for benefits.
Let’s get one thing straight: Applying for MassHealth is no easy thing when it comes to long-term care benefits. It is a long and arduous process, and it is filled with pitfalls. Mistakes that are made during the application process can sometimes be fixed, but sometimes they cannot be. We warn clients about trying to do this on their own because they can make mistakes that are impossible to come back from, and by the time they come to us, it's too late. You should never attempt one of these applications on your own or through a free service or even a company that claims to file applications on your behalf for a cheap price. This should be done by a lawyer and no one else.
The average turnaround time for a MassHealth application is at least 90 days. Once the application is put together, which takes some time because we are talking about reviewing five years' worth of documents, we submit the application and it can take MassHealth 60 days just to review the application and issue a letter acknowledging their receipt of the documents. Now that letter is not an approval. That first letter is almost always a request for further information.
MassHealth always finds some other piece of information to ask for, even when we think we've given them everything. One tactic they use, for example, is that because it takes them 60 days to respond, they'll come back and ask for additional bank statements to cover that 60 day period that it took them to open the application. They always find a way. Usually, that request for further information is answered by us and it takes them about 30 days to respond to that. So 60 days to respond to the application and then another 30 days to respond to the request for information. So right now we're at 90 days.
Sometimes the caseworker will still request additional information on top of that. They can be very difficult with determining what type of verifications they will accept and what type they will not. There are times when we think we've given them every possible document to prove a certain situation or asset, and they still find ways to question it.
Most nursing homes that accept MassHealth understand that this process can take roughly 90 days. MassHealth will pay retroactively for 90 days once the approval is granted. In this situation, the caseworker asked for more information at the 60-day mark, which we responded to. Much of the information they requested had to do with the fact that Jim and his son shared the same name. Now, this is something I'm used to because my dad and I share the same name, and so does my son, and I know it can be confusing. The caseworker sent us repeated requests to prove which assets were in Jim's name and which assets were in his son's name. It was no easy thing and MassHealth made an issue out of it over and over again.
This application was done in late 2020, and the 60-day letter came in around March, right at the beginning of lockdown because of COVID. At that point, the MassHealth caseworkers were working from home and there was very little staff actually in their offices. MassHealth continued to go back and forth with us making ridiculous requests for information to differentiate Jim’s assets from his son’s, all of which we provided.
Yet additional time went by with no response from MassHealth. The next thing we received was a notice from the nursing home that they wanted to evict Jim for nonpayment! Their position is understandable because it has now been six months since Jim moved in and they have not received any money when they should have gotten over $10,000 per month. I had to file an appeal of the eviction because the eviction was no fault of Jim's - it was because MassHealth was dragging its feet.
We had an appeal hearing and the MassHealth board of hearings sided with us and forced the nursing home to withhold the eviction for the time being, because we had a pending MassHealth application. I have no doubt that the eviction would not have been halted if Jim’s son wasn’t working with a lawyer.
Additional time went by and we received a notice from MassHealth, figuring that we will finally get the approval.
We open the letter and it is a denial for benefits saying that they did not receive documentation that they asked for in a timely manner. Take a look at that letter from MassHealth below.
We went back through our records and we had letters and mailing information of varying days and times, and we could not find any place where they had asked for something and then not received it in a timely manner. We notified MassHealth of this, and we listed all of the dates that we delivered documents and responses. MassHealth came back to us and said they never received the information that we sent on a particular date. Well, smartly, we had sent this information by UPS and we had proof of delivery from our UPS account (see, not our first time dealing with this agency!). We filed a response with MassHealth showing the information that we had sent by UPS, along with the UPS proof of delivery, and thought the problem was solved. Now, this was in the midst of COVID lockdown, so I completely understood that there may not have been adequate staff at the office to open and scan mail, and I was not pointing fingers or laying blame on anyone. I was simply trying to show that we did what was asked and that we did so in a timely fashion.
You’d think that the UPS proof of delivery would be the end of it, right? Wrong!
MassHealth came back to us and said that they still never received the information we had sent, despite the fact that we had proof of delivery from UPS. Instead of just making the assumption that the documentation could have got lost while they were short-staffed due to COVID, they instead refused to acknowledge receipt of the information and reaffirmed the denial of the application. In my opinion, we had passed the point of insanity here. I had proof of delivery and I gave them a sworn written statement that the necessary information was included in the UPS envelope, but they refused to acknowledge it. They denied the application, and once again, we had to file an appeal.
Here's the problem with MassHealth appeals:
An appeal through the MassHealth Board of Hearings is called a Fair Hearing. That is not a proper name because they are anything but fair. This is essentially MassHealth policing itself. The Board of Hearings is part of the same overall government agency as MassHealth, and they have to rule on appeals where MassHealth is one of the parties in the appeal. In other words, to win the appeal, you have to get MassHealth to rule against itself. It is not an easy thing. What agency is going to rule against its own caseworkers?
We had the appeal (this is appeal number two) and by the time the appeal is scheduled, we're at a point where almost a year has passed. The nursing home is very angry because they have not been paid and there have been over $100,000 in bills that have accrued. The hearing date comes and I submitted a sworn affidavit stating that the information was sent to MassHealth in a timely manner, that I had proof of delivery from UPS, and that I myself put the documentation into the UPS envelope.
Understand that this appeal did not include any testimony from Jim or Jim's son. Because my office was the one that sent the information, all the testimony came from me. When a client gives testimony at a Board of Hearings hearing, the appeal officer may or may not find the client to be credible. But in this case, the witness was not the client, it was me. I've been in practice for 20 years and I have an impeccable reputation. I created a sworn statement that I signed and filed with the Board of Hearings saying that I personally put the information into the UPS envelope myself and sent it and provided proof of delivery. That should have been case closed.
The MassHealth caseworker continued to state during the appeal that they never received it. However, she was not working at the office at the time, and neither were most of the caseworkers because of the lockdown. I never thought that we would have a problem winning the appeal because I didn't figure there was any way they would find my testimony to not be credible. Well, I was wrong. And in my opinion, MassHealth reached a new low. It took them a full month to issue their decision and they upheld their denial of the application. In other words, they were saying that despite my testimony and the proof of delivery from UPS, they still did not believe us, despite the evidence. If you think that the Board of Hearings will believe the testimony of an ordinary citizen, remember that they refused to believe me, with absolutely no reason why.
I never thought they would stoop so low. I was certainly not going to take this lying down like they probably hoped that we would. At this point, there was 14 months' worth of payments owed to the facility and they were anxious at the nursing home to either be paid or to evict Jim. I know that it's not easy to have MassHealth make a ruling against their own caseworker, but I never thought that my testimony wouldn't be believed, and I thought that the fact that this happened during COVID lockdown really gave them the perfect excuse to explain why they lost the documents and approve the application.
When we received the denial of the appeal, we immediately took the next steps. If the Board of Hearings denies an appeal, you can file with the court for judicial review to the Massachusetts Superior Court. That's immediately what I did. I drafted a complaint against MassHealth and against the Board of Hearings and filed them with the Superior Court. I explained that my sworn testimony was 100% true and that MassHealth's failure to grant the application, regardless of what their caseworker said, was a miscarriage of justice and an unfair interpretation of the rules. We had proof of delivery for God’s sake! I filed that complaint on a Friday with the superior court, and an electronic notice was sent to MassHealth.
On Tuesday, not even two business days later, I received a notice from MassHealth.
Not only were they approving the application, but they were approving payment all the way back until the day that Jim moved into the facility. There was no explanation given whatsoever. The truth of it is that they received the notice that we were not simply going to accept their denial and that we were taking the next steps of filing with the court. They knew that I would go into court and make them look foolish.
They also knew that I would have asked the court for MassHealth to cover my attorney's fees because it would be unfair to ask my client to do so. I was ready to go in front of the judge and make the hearing process and the hearing officer look ridiculous. MassHealth must have decided they did not want to look foolish and pay additional attorney fees, so they approved the application and are sending payment to the nursing home of over $150,000.
We secured a $150,000 victory for our clients.
Jim will be allowed to remain in the nursing home without fear of eviction. The nursing home will get paid and justice was done. Jim deserved better than this from the get-go. A war veteran who worked hard all of his life deserved better from a system that he paid into for his entire lifetime. It never should have taken this much effort and this much time to have his application approved. But when you're dealing with MassHealth, they hold all the cards and they make the rules. They stretched this thing out and still ruled against us, despite my testimony and written proof that we provided. They had no legal leg to stand on, yet their board of hearings ruled against us.
I was and still am shocked by this. I don't think I've had another case that more aptly demonstrates the fact that you should not be attempting MassHealth applications, and definitely not appeals, on your own without an attorney. They were expecting that they would simply deny the application and we would just go away. Their goal is to wear you down, and if you don't know the rules, it's very easily screwed up. It was only because of our expertise and knowledge with regard to MassHealth regulations and procedures, that we were able to have this application approved. This was a real victory for Jim and his son.
The best advice I can give is don't try this at home! Let us handle the application for you. With this victory, I maintained my 100% approval for MassHealth applications. That means I have never filed an application that I was not able to get approved. Our success rating for MassHealth applications remains at 100%, and Jim is receiving the benefits that he worked so hard for all of his life.
To learn more about MassHealth applications, download a free copy of my second book, The Long Game, here. This book describes the long-term care application process and the pitfalls to avoid.