“A Medicaid Worker Told Me I Cannot Get Medicaid”

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Art: Robin Mead

Pansy’s Story

My local Social Services and Medicaid Department were completely clueless about the particular Medicaid program I was applying for. I had to find the actual employee training manual and educate them about it and they still refused to find me eligible. So, I sent a complaint to the state level. Finally I was approved, and got a $40,000 hospital bill paid. Read Pansy’s Story

Azalea’s Story

While I was applying for a Medicaid Waiver, I switched to a new caseworker. She told me that the program requires that I be approved for Social Security disability first. I’d read the regulations and did not see that. We went back and forth, and I finally told her this: “If I not eligible for services, I’d like a formal written denial so that I can file an appeal.” What happened next? Read Azalea’s Story

Karen’s Story
– by Karen Carpenter

I am in a Medicaid Buy In for disabled workers. It has been quite the ride figuring it out. Local Medicaid office seem to know about this program. People who counsel and sell Medicare plans don’t about it either. Finally, someone gave me a number a for state office on insurance. They explained it.

Now I’m finally in the program and it pays for my Medicare co-pays, part B, and my premiums.  I also have a mountain of papers and a borage of useless Medicare marketing calls and mailings. I hope it gets better. This is the most inefficient use of our tax dollars.

Sweet Pea’s Story

My sister was being charged over $300 per month by medicaid in “share of cost.” She is poor and disabled and couldn’t pay this and also pay her rent. She started tutoring a neighbor’s child, and we helped her apply for Medicaid for Working Adults with Disabilities. Now she tutors a few afternoons each week (which she likes doing) and she pays $20 per month for Medicaid. All her medical expenses are covered.

Heidi’s Story
– by Heidi C. Johnson

My Medicaid spend-down was miscalculated three different times. Finally, I filed a complaint and got to speak to a supervisor.

The end result was I saved $3,000 per year on the spend-down, and got my Medicaid backdated by six months.

Some Medicaid employees have an imperfect understanding of how to apply different regulations and formulas. You will get a different story depending on who you talk to.

Carnation’s Story

For three years, I was told by everyone that I was not eligible for Medicaid. No matter how many places I called, and no matter how many people I spoke with, and no matter how desperate I was, no one ever told me about Medicaid waivers.

I couldn’t afford any of my medications, our house was going to be foreclosed on because of medical bills, and my husband was missing more and more work to stay home and take care of me and was about to get fired.

Finally, I learned about Medicaid waivers. The income limit was much higher, they did not count any of my husband’s income, and they didn’t even care that we live in a sucky state where no one gets Medicaid.

After I got approved for a waiver, I was able to get a home aide so my husband could start going back to work. Once I was approved for a waiver, they also gave me Medicaid heath insurance, and it pays for all my doctors, hospitals, prescriptions, vision and dental. The program is no cost to us at all. They also are going to give me wheelchair ramps. Everyone should know about this program.

Aster’s Story

My brother had cancer and needed life-saving treatment. Medicaid told him the only program he qualified for was a Medicaid spend down (share of cost) program that would cost $700 per month. This was almost all his income and would leave him with nothing to live on.

Then we discovered that he was only $80 over the income limit to qualify for a different Medicaid program. He bought Medicare supplemental health insurance for $85 per month. Suddenly he was under the limit! He applied for Medicaid and got it! He pays the $85 for his supplemental insurance and all other healthcare costs are covered.

Your Story

If you get turned down for Medicaid, or if someone from the Medicaid office tells you that you are not eligible, don’t give up hope! Just get scrappy. A few things it might help you to know:

💗 The people who work at Medicaid often tell people that they don’t qualify. It is not always true.

💗 Some people apply and get turned down because there was a mistake made on their case.

💗 Many, many people don’t realize there is more than one Medicaid program. You may not be eligible for one, but you may be eligible for a different one!

💗 Find a program you want to apply for and learn the rules yourself! The rules are different in every state. The people who answer the phones at Medicaid often do not know all the rules. Medicaid policy manuals are usually available online.

💗 Important rule for any program you ever apply for anywhere: Never take no for an answer over the phone or verbally. The worst thing that happens is people get discouraged out of even trying to apply.

💗 If you can find the actual manual and rules and regulation that your state has, then if you are denied, you can find out why. If you find that you should be eligible, you can appeal. Look online to find the regs.

💗 If you discover that Medicaid is not following the regs, you can also contact your congressional rep. They can help get this corrected.

💗 Medicaid can back bill for 3 months before the time of application. So, if you have a big hospital bill in January, and then apply for Medicaid in February, when your application is approved, the hospital can bill Medicaid.

💗  If you get turned down, try contacting disability rights organizations. In some states, they offer legal assistance to help people with Medicaid appeals. You can also appeal on your own.

What to Say When Someone Tells You “No” or “Not Possible” or “You Don’t Qualify”

💗 There are a few magic sentences you can say that can turn a No into a Yes!

💗 Also try these tips for: How to Have a Good, Helpful, Pleasant, Reasonably Successful Phone Call With a Social Service Agency

💗 Don’t forget the Golden Rule The Golden Rule: Never Take No for an Answer Over the Phone. Always get a written decision.

16 thoughts on ““A Medicaid Worker Told Me I Cannot Get Medicaid””

  1. Hello,
    My sister and I are 32 yrs old. Just recently on September 2019 switch to our dads retirement social security benefits DAC. We were on ssi since 18 yrs old 2006. We were given Medicaid, but we are on our mom’s health insurance since and the Medicaid became our secondary policy. Today 0ctober 23rd 2019 our Medicaid got cancelled because we are now off ssi. We will remain on our mothers health insurance for the two year waiting period for Medicare which is fine, but what happens if she looses her job or dies. Would we still be able to reapply for Medicaid until the two years is up for medicare if it lets say happens after enrollment period like in the middle of the year.

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  2. What a kind and generous thing you’re doing with this website. I don’t have any resource info. I’m in a small town and we don’t have a lot of services here.

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  3. Hi want to say thank you for all this great information!
    I wanted to ask your advice on my situation (warning***long story*** sorry.) I live in New Jersey
    I was approved for SSI on August 2018 had medicaid but then it was terminated and was told i needed to apply to aged,blind and disabled medicaid,so i applied and i was denied because although i told the worker i had money in my bank account due to lump sum payment from SSI she neglected to document this information. I appealed and when i went to the office hearing(not court) i explained Again and they apologized and even wrote a letter rescinding the denial. and was asked for other bank statements(another long story) which i quickly mailed in(next time i’ll go in person) waited and waited no medicaid so i called then told that he put ” statements aside” because it wasnt “marked”. but My name WAS on the envelope AND bank statement. now i had to wait for a decision…? i thought i was ok but still no medicaid Now they are saying that because I neglected to let them know about the lump sum i have to wait some more it’s been over 3 months. My neurosurgeon says the brain tumor might be returning he wants me to see an Oncologist but cant i have bills piling up.I had a stroke during surgery and my left arm is paralyzed i have fallen a couple times. and cant get my home assistant paid without medicaid,Ive asked about retro active pay for her and was already no. I’m stuck Dont know where to go next. thank you in advance

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    1. So sorry this happened. I think the best thing to do would be to contact your congressperson’s office. You might also try local legal aide program. Some states have Medicaid ombudsmans programs or patient advocates. If you were sent a letter with outcome of hearing showing you were approved, you could enclose this when you contact people. Hope something here helps: https://howtogeton.wordpress.com/2017/05/22/how-to-get-help-from-your-congressperson/

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  4. Hello, unfortunately I am stuck and this is because I was put on SSI for one month December 2018 and now I am being switched to Disabled Adult Child Benefits. I was 21 when this happened, I became disabled in 2017 at age 19. I found your loophole for how to keep medicaid under medicaid continuations. I printed this out and presented this to the welfare office first and was told that since my medical is tied to my benefits I had to go to social security Administration. I presented this to them and was told no that I only can get medicare “because I am automatically enrolled” and apply for QMB program, at the welfare office!!! lol. so I went back to the welfare office applied for QMB and medicaid again and provided loophole information again. I don’t understand, I did my research and provided evidence of my rights. I don’t know what the next step I should take. Should I write my congressmen? I will not stop fighting for medicaid, I just don’t know where to start.

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    1. I am not certain if the rule for continued medicaid would apply if you were never actually put on SSI medicaid. But I think it’s great that you want to try to find out! 🙂

      I think the next step is to appeal. It may help if you could get ask how you can get some kind of written denial notice so you could appeal it. If they tell you that you are not eligible, you could try requesting that decision in writing. You could also try contacting congressperson.

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      1. Also I recevied a new Medicaid card for the ssi medicaid effective 12/1/18 but it expired on the 31st Becuase of the change. And my local welfare always has a problem of sending me mulitpe letters that state 5 different things. For example after I went to to welfare office and presented the determination letter for ssi and ssi Medicaid (that letter also stated the loophole you found) and I gave them my award letter for DACB and the claim that medicare is in effect feburany 2019. The following week I got 3 letters from the income support divison all dated December 21st.

        The following reads:
        1. My medicaid has been terminated Becuase I no longer receive SSI and how to apply for medicare.
        2. Medicaid is terminated due to loss of SSI and I will continue to receive Medicaid until March 31st 2019 if the state can’t find a medicaid program to fit me under.
        3. Medicaid is being terminated December 31st 2018 but that I am approved for only February 2019 when thats when supposedly medicare kicks in? Makes no sense.

        My local welfare office always tries to send me to a social security office and obviously social security does not handle medicaid and medicare.

        Very frustrating that I can never get a clear answer. Thank you for listening.

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        1. Oh, interesting! How do you know it expired? Did you receive a letter saying it was ending? That letter should give you information on how to appeal. When you appeal, enclose a copy of the regulation for continued medicaid for DAC. If that appeal doesn’t work, there may be a next level of appeal. Your state medicaid office may also have some kind of medicaid ombudsman (patient advocate) you could talk to.

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          1. The only way I know it expired on December 31st is that I go to at least 4 doctor appointments a month and every time I went, I was givin a heads up by my doctors about it. I talked to my care coordinator from my insurance and comfirmed that it is cancelled on December 31st. Went to the welfare office was told that I could not be helped and go to the social security office when all there letters I mentioned above are from income support division (human services department) not social security. I have resquested time and time again to talk to a case worker or patient advocate nut get denied every time. I just made my trip yesturday to the social security office after being turned down at the welfare office several times and was given a statement about my change in income and medicare chamge in February along with premium cost. Also told to provide my ssi Medicaid card and loophole the next time I vist the welfare office to apply for Medicaid. I am going tomorrow morning. Wish me luck.

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            1. Good work persisting!! I don’t know how the process works in your state, but my advice is: try requesting something in writing confirming your medicaid is ending. Ask how you can make a WRITTEN appeal. Keep asking to speak to supervisors and let them know you want a WRITTEN decision and you want to appeal in WRITING. No matter what anyone says to you, you do not want to miss the deadline to make an appeal in writing 🙂

              If you let me know your state I can try to see if I can find an ombudsman office phone number, if there is one.

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              1. I live in new mexico if you could find that number it would be greatly appreciated. My welfare office was closed today due to the snow. They will be open tomorrow. I will try to get something in writing, thank you for you help and cooperation.

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                1. Not sure if they will be helpful, but you could try these folks:
                  https://www.osi.state.nm.us/ManagedHealthCare/consumer-guide-external-review.aspx

                  some general info on appealing medicaid denials
                  https://www.nolo.com/legal-encyclopedia/how-appeal-denial-medicaid-non-eligibility.html

                  story from a reader who contacted at the state level and got her medicaid approved:
                  https://howtogeton.wordpress.com/2017/07/30/how-pansy-got-on-medicaid-after-being-told-she-cant-get-on-medicaid/

                  regional contact info: https://www.medicaid.gov/about-us/contact-us/index.html

                  more contact info, I would not bother with the customer service ones: http://www.hsd.state.nm.us/Contact_Us.aspx
                  http://www.hsd.state.nm.us/Medical_Assistance_Division.aspx

                  hope this helps

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  5. I really like what you said about not taking no for an answer when trying to talk to someone about medicaid and how to properly apply for it. This is something that I have been struggling to get for a long time. It would be great if I could meet with a specialist that could help me with receiving medicaid.

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