Hi fredboy,
The state Medicaid agency is responsible for administering Medicaid
(in your case, the Tennessee Medicaid Office). If there is a dispute
regarding eligibility, your father will be entitled to request a "fair
hearing" after he receives written notice of the denial from the state
Medicaid agency. It is your father's responsibility to request the
fair hearing and seek legal aid (advocacy programs are available to
help, and contacts are supplied in the written notice).
Centers for Medicare and Medicaid Services:
Table of Contents for the State of TN:
http://www.cms.hhs.gov/medicaid/stateplans/toc.asp?state=TN
CONTACT:
Tennessee Medicaid Office
Department of Finance and Administration of Tennessee
729 Church Street
Nashville, TN 37247
Local: 1-615-741-4800
Toll-Free: 1-800-669-1851
"Please remember that you need to contact Department of Finance and
Administration of Tennessee offices to obtain information regarding
enrollment, eligibility, and coverage in Tennessee. Please use the
information provided above to either visit Department of Finance and
Administration of Tennessee website or use the phone number to contact
them."
http://www.cms.hhs.gov/medicaid/state.asp?state=TN
Appealing Medicaid Decisions:
"Under federal Medicaid law, a Medicaid applicant or recipient is
entitled to an administrative hearing any time a decision is made
which affects his or her right to Medicaid or to any service for which
Medicaid funding is sought. This is known as a "fair hearing" and will
be available in all states."
"A person whose Medicaid benefits or right to services funded by
Medicaid are either denied or terminated is entitled to a written
notice of that decision. The notice must explain: the action that is
being taken, the reason for the action, the right to a hearing to
appeal the decision, and the availability of free services from a
Legal Services, Legal Aid or similar program (such as a Protection and
Advocacy program). States are permitted to establish their own time
limits for requesting hearings. Typically, the Medicaid recipient will
be permitted a time limit (30 - 60 days) for requesting the hearing.
However, if the notice indicates that an ongoing benefit, such as
funding for home health care services, is to be terminated on a
certain date, the recipient will need to request the hearing before
the termination date if continued services are going to be requested
pending the appeal. Federal Medicaid law provides that benefits are to
be continued pending the appeal (a concept often referred to as "aid
continuing") if the hearing is requested before the effective
termination date and the recipient (or advocate working on his or her
behalf) specifically requests the continuation of benefits.
http://www.ilr.cornell.edu/ped/ssa_curriculum/2003_BPAO/2003_TEXT/Section4/Chapter18.htm#9
THE MEDICAID RESOURCE BOOK
Chapter I: Eligibility:
http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14259
Chapter IV: Administration:
State Medicaid agencies administer the program on a day-to-day basis.
Primary duties of a state Medicaid agency include:
? Informing individuals who are potentially eligible and enrolling
those who are eligible.
? Determining what benefits it will cover in which settings.
? Determining how much it will pay for covered benefits and from whom
it will purchase services.
? Processing claims from fee-for-service providers and making
capitation payments to managed care plans.
? Monitoring the quality of the services it purchases.
? Ensuring that state and federal health care funds are not spent
improperly or fraudulently.
? Collecting and reporting information necessary for effective program
administration and accountability.
? Resolving grievances by applicants, enrollees, providers and plans.
Processing Appeals:
"In any health insurance program there will be disputes among
patients, providers, and payors over whether particular services meet
the standards for payment. In the means tested Medicaid program, these
coverage disputes are augmented by disputes arising in connection with
the determination and redetermination of eligibility. Because Medicaid
is an entitlement to individuals as well as to states, state Medicaid
agencies are subject to constitutional and statutory ?due process?
requirements regarding denials of eligibility or coverage. In
particular, state Medicaid agencies are required to grant an
opportunity for a ?fair hearing? to each individual (applicant or
beneficiary) whose claim for Medicaid benefits is denied or is not
acted upon with ?reasonable promptness.
The ?fair hearing? entitlement includes the right to written notice of
the opportunity to request a fair hearing, the right to a hearing
before an impartial decision-maker, and the right to the continuation
of benefits pending the hearing decision. The ?fair hearing?
protections apply to all Medicaid beneficiaries, including those who
are enrolled in MCOs and seek to challenge denials or delays of
covered services.
Beneficiaries who are residents of nursing facilities also have a
right to a hearing in the event of an involuntary transfer or
discharge."
http://www.kff.org/medicaid/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=14262
Additional Links of Interest:
Medicaid and Medicare Nursing Home Basics:
http://www.elderlawanswers.com/resources/s7/r36958.asp
Centers for Medicare and Medicaid Services, formerly the Health Care
Financing Administration's Web Site:
http://www.hcfa.gov
Not-for-Profit Agency Web Sites:
National Health Law Project
http://www.healthlaw.org
National Senior Citizens Law Center:
http://www.nsclc.org
National Assistive Technology Advocacy Project:
http://www.nls.org/natmain.htm
I hope I've been able to help you sort this all out. If you have any
questions, please post a clarification request before closing/rating
my answer and I'll be happy to respond.
Thank you - and good luck!
hummer
Google Search Terms Used
"medicaid resource book"
medicaid advocacy tennessee
tennessee "appealing medicaid decisions"
tennessee medicaid appealing
tennessee medicaid
tennessee state medicaid agency
tn medicaid appealing
plus following many links within websites |
Request for Answer Clarification by
fredboy-ga
on
22 May 2004 05:29 PDT
I may have missed this somwhere..
At what point in the proccess does the state send someone out to SEE
them and their charts etc?
If we start the appeals proccess...
who pays the bills ( when their 100 medicare days end) ! Does the
nursing home wait and get arrears?
Do they get "put out" on the street ?
Is this now the homes responsibilty or stil me and my sisters?
Of course they may GET accepted right away..
Just wana be prepared !
|
Clarification of Answer by
hummer-ga
on
22 May 2004 07:55 PDT
Hi fredboy,
Thank you for your clarification. Ok, let's see if we can nail this down for you.
Have your parents (or you on their behalf) already applied for
TennCare Medicaid at the Department of Human Services (DHS)? What did
they say? Are your parents eligible to apply for TennCare Medicaid? If
not, did they apply for TennCare Standard?
Thanks,
hummer
|
Request for Answer Clarification by
fredboy-ga
on
22 May 2004 09:01 PDT
fredboy,
Thank you for your clarification. Ok, let's see if we can nail this down for you.
Have your parents (or you on their behalf) already applied for
TennCare Medicaid at the Department of Human Services (DHS)? What did
they say? Are your parents eligible to apply for TennCare Medicaid? If
not, did they apply for TennCare Standard?
Thanks,
hummer
Hummer... The application has been made and the "PAE" or application
for benefits sent from Chattanooga ( where they are) to Nashville (
where I am)
the capitol . It was sent around early 2nd week April. We have NOT
heard bac from them as of yet one way or the other ( parents on the
100 days of skillable
medicare coverage which will run out soon) I do not know if Tenncare
for their meds docs etc has been applied for. My sister is doing the
"work" in Chattanooga.. Im just
doing the reasearch here in Nashville. If Tenncare was deemed needed
to be aqpplied for...Im sure the social worker or admin at the nursing
home would have had her (or do it themselves as they did medicaid
application for us)
Hope this clarifies your request for clarification of my request for
clarification ! :)
fred
|
Clarification of Answer by
hummer-ga
on
22 May 2004 09:38 PDT
Hi fredboy,
Let's deal with one issue at a time - first, the medical end of your
question and then we'll move on to the appeal.
"At what point in the proccess does the state send someone out to SEE
them and their charts etc?"
"The application has been made and the "PAE" or application for
benefits sent from Chattanooga ( where they are) to Nashville (where I
am) the capitol."
The PAE stands for "Pre-Admission Evaluation". If the PAE has already
been filed, that means your parent's medical provider has already
assessed them and filled out the form. It should just be a matter of
waiting to see if they are accepted or not.
WHAT ARE THE MEDICAL ELIGIBILITY GUIDELINES?
"The Medical application called a PRE-ADMISSION EVALUATION (PAE) IS
USUALLY FILLED OUT BY THE MEDICAL PROVIDER. This application is then
sent by the medical provider to the TennCare Bureau. The state looks
at the application and determines if you need nursing -level care on a
daily basis."
WHAT CAN I DO IF THE STATE OF TENNESSEE DECIDES I AM NOT ELIGIBLE?
"APPEAL! If you are turned down for financial or medical reasons you
will be given a right to appeal in the notice. Be sure to read the
notice carefully for the number of days you have to appeal If you miss
the appeal deadline, you may lose the right to appeal."
http://www.setnlegalservices.org/financing_long_term_care_in_tenn.htm
Medical Eligibility. To determine medical eligibility for Medicaid,
applicants must have a Medicaid-approved examination called a
Pre-Admission Evaluation and a mental health screening (pre-admission
screening and annual resident review, or PASARR). The PAE determines
the level of care a patient needs and whether the patient meets
Medicaid?s medical criteria. The PASARR determines if the patient has
any mental illness or mental retardation that require special
treatment. If so, the applicant cannot be admitted to a nursing home.
If the Bureau of TennCare approves the applicant?s PAE, the applicant
is medically eligible for Medicaid."
http://www.thca.org/paying.htm
>>>>>>>>>>>
"If Tenncare was deemed needed to be applied for...Im sure the social
worker or admin at the nursing home would have had her (or do it
themselves as they did medicaid application for us)."
The Medicaid you are applying for *is* TennCare (TennCare Medicaid).
Please let me know if that all makes sense or if you have any other
questions. I'm all yours for the day, and it's impossible to post too
many clarifications - as they say, "let's do this thing." 8-)
hummer
|
Request for Answer Clarification by
fredboy-ga
on
22 May 2004 12:07 PDT
Thanks Hummer your a Godsend if you dontr realise it:
OK
IF we get shot down...
Who pays the tab/where do they go whie we appeal and do we NEED an
elder care atty?
We were told do the PAE early on when they look theyre "worst"
Dad IS bi polar dissorder under control is not retarded nuerotic as hell
Will we be able to keep mom and dad TOGETHER at this awesome facility
assuming Approval? ! He seems to manage fine mentally...mild dimentia tho.
Are ( Im such a pessimist or just scared s..less) appeals fairly easy to win?
Do they turn everyone down the "first" time they apply?
Man you are sent from heavan
I CANNOT THANK you ENUFF
|
Clarification of Answer by
hummer-ga
on
22 May 2004 13:53 PDT
Dear Fred,
Have a look at these:
New Applications:
Applicant Submits TennCare Medicaid/TennCare Standard Application:
http://www.thcc2.org/resources/newappflow.pdf
How Long We Can Take to Decide About Your Application:
...45 or 90 days...or longer for TennCare.
http://www.tenncareadvocacy.org/files/DHSinfo.pdf
How to File Appeal:
http://www.tenncareadvocacy.org/files/HowToFileAppealBrochure.pdf
"The medical component of the Medicaid program in Tennessee is called
TennCare. But you may be able to get TennCare even if you don?t
qualify for Medicaid. TennCare is now two programs: TennCare Medicaid
and TennCare Standard. You can apply for TennCare Medicaid by going to
the Department of Human Services (DHS) and completing a Medicaid
application. DHS will be able to tell you if you meet the guidelines
for Medicaid. If you are not eligible for Medicaid, you may be
eligible for TennCare Standard. You can apply for TennCare Standard at
DHS. To qualify for TennCare Standard you may need to prove you are
medically eligible."
http://www.tenncareadvocacy.org/faq.html#17
>>>>>>>>>>>>
Your questions:
If we start the appeals proccess...
"who pays the bills ( when their 100 medicare days end) ! "
You do.
"Does the nursing home wait and get arrears?"
They probably will give you a grace period - it is up to them.
"Do they get "put out" on the street ?"
I'm sure they won't while your application is still being processed or appealed.
"Is this now the homes responsibilty or stil me and my sisters?"
No, it's not the home's responsibility (have your parents given you
Power of Attorney?).
>>>>>>>>>>
"Who pays the tab/where do they go whie we appeal and do we NEED an
elder care atty?"
No, you do not need an attorney although it wouldn't be a bad idea to
consult with legal aide. The contacts are supposed to be included with
the rejection notice.
"We were told do the PAE early on when they look theyre "worst"
Dad IS bi polar dissorder under control is not retarded nuerotic as
hell. Will we be able to keep mom and dad TOGETHER at this awesome
facility assuming Approval? ! He seems to manage fine mentally...mild
dimentia tho."
Unfortunately, I don't think they will be assessed as one unit - they
each will receive separate assessments. If they are both approved, I
don't see why they couldn't stay together.
"Are ( Im such a pessimist or just scared s..less) appeals fairly easy to win?
Do they turn everyone down the "first" time they apply?"
I've not read anywhere that new applications are routinely turned down
and I highly doubt that that would be the case. If it were true, it
would increase the traffic to the court of appeals and I'm sure the
courts wouldn't look too kindly on that.
>>>>>>>>>>>>>
Fred, I would do this:
1) Ask the nursing home how long a grace period they will give you
after the 100 day deductable has ended. I'm *sure* that they have a
policy in place for taking care of residents while TennCare is in
deliberation or being appealed.
2) Write down all of your questions and call TennCare - that is what
they are there for. I tried calling, but they are closed on Saturdays.
They're open 8 - 4:30 Mon - Fri. If you call them today, you'll be
able to listen to a brief recorded explanation of TennCare.
TennCare: Toll-Free: 1-800-669-1851
3) Persistence is the key. You're dealing with a mega-bureaucracy,
each worker knows about their own little world but they don't see much
beyond that. Even when things look the bleakest, if you continue to
persevere, more alternatives will usually pop up, but you have to keep
probing and looking under every rock. Don't take just one person's
opinion or advice - ask another person, and another, and another. We
know from personal experience with nursing homes that often you have
to keep digging (and pestering!) to find information or more options
that are open to you.
4) Try to relax - you are not doing yourself or your parents any good
by thinking the worse. It is one thing to *plan* for the worse, but it
is another to *think* the worse. If you believe in karma, or vibes, or
whatever you want to call it - good thoughts help (if nothing else,
they'll help to keep your blood pressure down 8-)).
5) Promise to let me know when the TennCare decision comes in - after
all this, I would really like to know how it goes!
I *think* I've answered all of your questions except for that pesky
100-day potential problem - I'm sure the nursing home people are the
ones to ask about that one. If anything else is unclear, or I've
misunderstood you, or whatever, just give a whistle and I'll have
another look.
Take care, Fred,
hummer
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