“Medicaid Pending” is the term used for when a person has applied for Medicaid, but has not yet been approved or denied benefits. This period can be difficult and stressful. This is because in most cases, seniors require long-term care during this interim period, but they cannot afford to pay for their cost of care.
There are some nursing home facilities, assisted living residences, and even in-home care providers, who will provide services for seniors in a Medicaid Pending status. This allows applicants to receive services / care on the assumption that they will be approved by Medicaid and the care provider / residence will be paid retroactively. Said another way, the facility and providers will be reimbursed for the cost of care of Medicaid approved benefits from the date the Medicaid application was filed. Care recipients are not responsible for paying fees associated with the care received during “Medicaid Pending”. For nursing home care, the resident is not responsible for the cost of room and board either. With assisted living, Medicaid will never cover the cost of room and board. More on Medicaid and assisted living.
It is generally nursing home care that one requires while a Medicaid application is pending. Therefore, the focus of this article is “Medicaid Pending” nursing home care.
Retroactive Medicaid differs from Medicaid Pending. This allows Medicaid to pay for services for up to 3-months prior to one’s date of application if one is determined Medicaid-eligible during the “retroactive” period. More.
Nursing home residences do not receive payments from a state’s Medicaid agency for a “Medicaid Pending” resident. While payments are essentially put on hold until a Medicaid determination is made, residents in this status are generally expected to pay the majority of their income to the nursing home as a share of cost / patient liability. Nursing home residents are permitted a small Personal Needs Allowance (PNA). This amount is state-specific. For example, in 2024, the following states allow PNA’s in the following amounts: California ($35 / month), Texas ($75 / month), and Florida ($160 / month). The cost of health insurance premiums, such as Medicare, may also be deducted from one’s income.
If the “Medicaid Pending” applicant is married and their spouse is not also applying for Medicaid, the applicant can transfer part (or in some cases, all) of their income to the non-applicant spouse. This Spousal Income Allowance is called a Monthly Maintenance Needs Allowance and is intended to prevent the non-applicant spouse, commonly called a community spouse, from becoming impoverished. In 2024, in most states, the maximum amount of income that the applicant spouse can transfer to their non-applicant spouse is $3,853.50 / month.
Following the deduction of one’s Personal Needs Allowance, health insurance premiums (if applicable), and Spousal Income Allowance (if applicable), the remainder of the resident’s income is paid to the nursing home when an applicant is Medicaid Pending.
Some nursing homes may ask the resident’s family to pay for the full cost of care while the elder’s Medicaid application is pending. It is highly advised that the family does not make this financial commitment. If the family covers the cost of care in the interim, they very likely will not be repaid once the application is approved.
Upon approval of a senior’s Medicaid application, Medicaid will reimburse the nursing home for the period that a resident was in “Medicaid Pending” status. Moving forward, the state’s Medicaid agency will make nursing home payments and the nursing home resident will continue to pay their share of cost. If an applicant is denied Medicaid, the nursing home will attempt to collect past due bills from the resident and / or their family members.
Not all nursing home residences accept persons who are in “Medicaid Pending” status. In fact, some states prohibit persons from applying for Nursing Home Medicaid until they are physically residing in a Medicaid-certified nursing home. One example is Georgia, which requires 30 days in a nursing home prior to application. Even in states that do not require one to be in a nursing home, it can be a challenge to find facilities that will accept persons who have not yet been accepted into their state’s Medicaid program. This is because the nursing home is taking a risk; they cannot be certain that the applicant will be approved. If the applicant is denied Nursing Home Medicaid, Medicaid will not reimburse the facility, and in most cases, the nursing home will simply not be paid.
Nursing home facilities also limit the number of beds for Medicaid-funded residents. Therefore, it is not a clear cut “yes” or “no” as to if a nursing home will even accept Medicaid-funded residents. When all of the Medicaid-funded beds are filled in a Medicaid-approved residence, they will not accept any more residents on Medicaid (or in Medicaid Pending status) until a bed becomes available. Even if a nursing home residence does have a Medicaid-funded bed available, it may not accept a resident with a Medicaid Pending application.
The best approach to finding Medicaid Pending nursing homes is to make a list of Medicaid nursing homes in the area, contact each one, and ask directly if they will accept Medicaid Pending residents.
Once Medicaid-funded nursing homes that accept “Medicaid Pending” residents have been located, persons should submit a copy of their Medicaid application, as well as documentation supporting their application (i.e., documentation proving that functional need, financial eligibility, residence criteria, etc. is met) to the nursing home residence. Persons should take extra caution to ensure the application is filled out correctly for the best chance of Medicaid approval.
Some states do not allow persons to apply for Nursing Home Medicaid until they are physical residing in a nursing home. Georgia is one such state and requires 30 days in a nursing home prior to application.
Federal law states that Medicaid agencies have 45 days to process and either accept or deny one’s Medicaid application. For applications that require a disability determination, 90 days are allowed. Depending on the circumstances and the state in which one resides, the application process could be shorter or longer.
Not included in this estimate is how long it takes to prepare for the Medicaid application. Extensive documentation is required and many families spend weeks or months gathering these documents prior to submission. For persons who require long-term care, such as nursing home care, a functional assessment must also be completed. If the Medicaid application is filled out improperly and / or all supporting documentation is not submitted on time (or at all), the application process can take longer or the application may be denied. If the application is denied for these reasons, the process will take even longer, as one will need to start the application process all over again. If one is denied Medicaid benefits for another reason, they can appeal the decision. One’s denial of benefits letter will explain the appeal process.
There are public and private Medicaid Planners that can facilitate the Medicaid application process. Learn more.
It is vital that Medicaid applications are filled out correctly and all supporting documentation is provided to the Medicaid agency in a timely manner. The Medicaid application process can be complicated, particularly if an applicant is married or if it is questionable if an applicant meets the income and / or asset limit(s) in the state which they reside.
See state-by-state Medicaid eligibility requirements. Being over the income and / or asset limit(s) is not automatic cause for disqualification. Rather, the restructuring of one’s finances will be required. This is where Medicaid Planning strongly comes into play. For the best chance of acceptance into one’s state Medicaid program, it is highly suggested one seek the advice and expertise of a Medicaid Professional Planner. Find one here.