Was Your Medicaid Application Denied? Get a Second Opinion.
Revised October 12, 2023
Below is general information on eligibility for Oregon’s Medicaid for Long-Term Services program. The information below is not meant as legal advice. It should not be relied on as a substitute for consulting with an attorney about the specific facts of your particular situation.
Medicaid – What It Pays For
For those who qualify, Oregon’s Medicaid for Long-Term Services program is a government program that can help pay for the high cost of long-term care facilities such as Memory Care, adult foster care homes, residential care facilities and nursing homes. The program can also help pay for limited in-home care assistance. Medicaid is a different program than Medicare.
Not all long-term care facilities have a Medicaid contract with the state. If you think your family member or friend may need to apply for Medicaid to help pay for a long-term care facility, ask prospective facilities whether they accept Medicaid. Be warned that some Medicaid-contracting facilities have a practice of telling the families of prospective residents that the facility requires payment at the higher “private pay” rates for a certain period of time (from a few months, to a year or two) before the facility will allow the resident to pay the lower Medicaid rate (assuming the resident has by then applied and qualified for Medicaid). It is unclear whether this practice is legal in Oregon.
Why Would I Hire an Attorney to Help Apply for Medicaid? In short: Medicaid employees are not allowed to give legal advice. However, Medicaid attorneys are licensed to give legal advice. Hiring an experienced Medicaid eligibility attorney can be particularly useful when one spouse of a married couple is applying for Medicaid for Long-Term Services, but the other spouse is not.
There are Medicaid eligibility rules that may, in some circumstances and if applied correctly, save a married couple tens of thousands of dollars that they would otherwise believe they need to "spend down." The Medicaid eligibility workers are not going to tell you that this may be possible, much less tell you how to legally preserve funds.
Also, Oregon's "ONE" computerized application system is acknowledged to not handle Medicaid for Long-Term Services applications correctly. Younger and less-experienced Medicaid eligibility workers and case managers may not spot that the ONE system has misapplied (or even completely failed to apply) a Medicaid rule. An experienced Medicaid eligibility attorney should prepare his or her own calculations for comparison with the ONE system results.
IMPORTANT TIP: The ONE system is notorious for sending out confusing or even flat-out incorrect denials of eligibility in Medicaid for Long-Term Services applications. If you receive what looks like a denial of eligibility, immediately contact your Medicaid eligibility worker by email or by phone for an interpretation of the ONE system mailing that you received. If you get a denial of eligibility, it may have been caused by the application taking longer than the 45-day period mandated by the Medicaid rules. If one of the overworked and overwhelmed Medicaid case managers does not manually go into the ONE system and "pull the case" to prevent the 45-day denial letter from going out, it goes out. These official-looking but incorrect ONE denial of benefits letters likely cause significant anxiety to those trying to complete the application process.
Not all long-term care facilities have a Medicaid contract with the state. If you think your family member or friend may need to apply for Medicaid to help pay for a long-term care facility, ask prospective facilities whether they accept Medicaid. Be warned that some Medicaid-contracting facilities have a practice of telling the families of prospective residents that the facility requires payment at the higher “private pay” rates for a certain period of time (from a few months, to a year or two) before the facility will allow the resident to pay the lower Medicaid rate (assuming the resident has by then applied and qualified for Medicaid). It is unclear whether this practice is legal in Oregon.
Why Would I Hire an Attorney to Help Apply for Medicaid? In short: Medicaid employees are not allowed to give legal advice. However, Medicaid attorneys are licensed to give legal advice. Hiring an experienced Medicaid eligibility attorney can be particularly useful when one spouse of a married couple is applying for Medicaid for Long-Term Services, but the other spouse is not.
There are Medicaid eligibility rules that may, in some circumstances and if applied correctly, save a married couple tens of thousands of dollars that they would otherwise believe they need to "spend down." The Medicaid eligibility workers are not going to tell you that this may be possible, much less tell you how to legally preserve funds.
Also, Oregon's "ONE" computerized application system is acknowledged to not handle Medicaid for Long-Term Services applications correctly. Younger and less-experienced Medicaid eligibility workers and case managers may not spot that the ONE system has misapplied (or even completely failed to apply) a Medicaid rule. An experienced Medicaid eligibility attorney should prepare his or her own calculations for comparison with the ONE system results.
IMPORTANT TIP: The ONE system is notorious for sending out confusing or even flat-out incorrect denials of eligibility in Medicaid for Long-Term Services applications. If you receive what looks like a denial of eligibility, immediately contact your Medicaid eligibility worker by email or by phone for an interpretation of the ONE system mailing that you received. If you get a denial of eligibility, it may have been caused by the application taking longer than the 45-day period mandated by the Medicaid rules. If one of the overworked and overwhelmed Medicaid case managers does not manually go into the ONE system and "pull the case" to prevent the 45-day denial letter from going out, it goes out. These official-looking but incorrect ONE denial of benefits letters likely cause significant anxiety to those trying to complete the application process.
Oregon’s Estate Administration Unit
When Medicaid funds are used to help pay the cost of long-term care, the Estate Administration Unit (EAU) will make a claim against the estate of the Medicaid recipient after death for reimbursement of these funds. If the Medicaid applicant is survived by a spouse, the state will defer its claim until after that spouse dies.
Applying for Oregon Medicaid – the Online “ONE” System Versus a Long Phone Call or In Person Appointments In about February 2021, Oregon’s “ONE” system went online. Now Medicaid applicants have the option of directly applying for Medicaid online using the ONE system.
No one who has dealt directly with the online ONE system when applying for Medicaid likes it.
Fortunately Medicaid applicants have the alternate option of scheduling a Financial Intake telephone appointment with a Medicaid employee (variously called a screener, eligibility worker, or some other title) who asks questions and inputs the answers on her end into the ONE system. Be warned: this Financial Intake call is long. It can take anywhere from one and a half to four hours (or maybe longer).
If You Are Denied Medicaid, Consider Getting a Second Opinion If you are denied Medicaid, consider hiring an elder law attorney experienced in Medicaid eligibility to analyze the Medicaid applicant’s assets and give a second opinion. Ask questions when selecting your attorney. Not all elder law attorneys are experienced in Medicaid eligibility.
Many times someone applying for Medicaid is told early on in the application process, often after only a few questions by an eligibility worker, that the Medicaid applicant is “over resources” and thus does not qualify for the Medicaid program, or that the applicant does not qualify for another reason. This determination of ineligibility may be wrong. Or, even if the determination is accurate, there may be allowed planning steps that the Medicaid applicant could take to speed up Medicaid eligibility. Medicaid is currently significantly short-staffed. Its eligibility workers are overworked and short of time. It is not the screener’s job to give legal advice to Medicaid applicants or to the applicants’ family members.
Applying for Oregon Medicaid – the Online “ONE” System Versus a Long Phone Call or In Person Appointments In about February 2021, Oregon’s “ONE” system went online. Now Medicaid applicants have the option of directly applying for Medicaid online using the ONE system.
No one who has dealt directly with the online ONE system when applying for Medicaid likes it.
Fortunately Medicaid applicants have the alternate option of scheduling a Financial Intake telephone appointment with a Medicaid employee (variously called a screener, eligibility worker, or some other title) who asks questions and inputs the answers on her end into the ONE system. Be warned: this Financial Intake call is long. It can take anywhere from one and a half to four hours (or maybe longer).
If You Are Denied Medicaid, Consider Getting a Second Opinion If you are denied Medicaid, consider hiring an elder law attorney experienced in Medicaid eligibility to analyze the Medicaid applicant’s assets and give a second opinion. Ask questions when selecting your attorney. Not all elder law attorneys are experienced in Medicaid eligibility.
Many times someone applying for Medicaid is told early on in the application process, often after only a few questions by an eligibility worker, that the Medicaid applicant is “over resources” and thus does not qualify for the Medicaid program, or that the applicant does not qualify for another reason. This determination of ineligibility may be wrong. Or, even if the determination is accurate, there may be allowed planning steps that the Medicaid applicant could take to speed up Medicaid eligibility. Medicaid is currently significantly short-staffed. Its eligibility workers are overworked and short of time. It is not the screener’s job to give legal advice to Medicaid applicants or to the applicants’ family members.
Medicaid – Some Eligibility Requirements
A Medicaid applicant must need assistance with activities of daily living (e.g. help with mobility, eating, cognition) at the level and of the type that Medicaid will pay for. A Medicaid employee will conduct an assessment of the level of care/assistance needed. Because many Medicaid applicants are unable to accurately answer questions about what activities of daily living they can and cannot complete on their own or with assistance, it can be helpful for a knowledgeable family member or caregiver to be present throughout this assessment interview.
Monthly Income Limit Oregon’s Medicaid program has a monthly gross income limit, also called an “income cap,” but there is a workaround for those applicants whose gross income exceeds the income cap amount. This income cap applies to the income of only the Medicaid applicant. For married Medicaid applicants, the income limit does not apply to the income of the Medicaid applicant’s spouse, assuming that spouse is not also applying for the Medicaid program. The 2023 monthly income cap is $2,742.00. For those applicants whose monthly gross income exceeds the income cap, the workaround is executing a document called an Income Cap Trust and setting up and funding a checking account for that trust. A Medicaid employee should be able to provide an online link to the Income Cap Trust forms. Alternatively, you can pay a Medicaid elder law attorney to prepare an Income Cap Trust document and counsel you.
Countable Resource Limit Medicaid categorizes “assets” into two subcategories: income and resources. If an asset is not income, then it’s a resource. “Resources” have further subcategories such as: countable resources, excluded resources, temporarily excluded resources, and unavailable resources.
Unlike income (where only the Medicaid applicant’s income, and not the spouse’s income, is counted for eligibility purposes), Medicaid counts resources owned by either the Medicaid applicant or the spouse, or owned by both of them. In other words, for eligibility purposes Medicaid counts the couple’s combined countable resources. A Medicaid applicant is allowed to keep $2,000.00 in countable resources. If the Medicaid applicant is married and the spouse is not also applying for Medicaid, then the spouse is allowed to keep a portion of the couple’s combined countable resources as calculated under OAR 461-160-0580. (OAR = Oregon Administrative Rules.) The spouse’s allowed portion of the couple’s combined countable resources is known as the Community Spouse Resource Allowance, or CSRA. There are many misunderstandings about how the CSRA—the spouse’s portion of the couple’s combined countable resources—is calculated. One important point that may have a significant financial impact is the date as of when the couple’s combined countable resources are valued (for example, the date of bank account balances; the date of a vehicle’s value; the date of a real property valuation). Under OAR 461-160-0590(1), if requested, the couple’s combined countable resources are to be assessed “at the beginning of the most recent continuous period of care”:
The Department assesses a couple's combined countable (see OAR 461-001-0000) resources at the beginning of each continuous period of care when requested by either spouse or by a representative acting on behalf of either spouse (see OAR 461-001-0000).
Medicaid attorneys often use the term “snapshot date” as shorthand for “the beginning [date] of the most recent continuous period of care.” Using the wrong “snapshot date” to assess a married couple’s combined countable resources can sometimes result in a determination that the couple is “over resources” when actually they are not. Using the wrong “snapshot date” can also sometimes result in a couple being told, incorrectly, that they need to “spend down” tens of thousands of dollars before they will be resource eligible, when with a resource eligibility determination calculated using the correct “snapshot” date they could qualify with much less of a “spend down.”
Gifts and the Penalty Period
Another barrier to Medicaid eligibility for some is violating the disqualifying transfer of assets rule, OAR 461-140-0242, also known as the gifting rule. If the Medicaid applicant or the Medicaid applicant’s spouse, or someone acting on behalf of one or both them, transfers an asset for less than fair market value during the sixty months (5 years) prior to the date of request for Medicaid, a penalty period may be imposed. The Medicaid applicant will be ineligible for the Medicaid program during the penalty period. This sixty month/5 year period is sometimes called the “look back period.”
If this is your situation, do not give up hope. There are exceptions to the gifting rule. Also, the screener or case manager assigned to your application may use their discretion and decide that imposing a penalty period is not appropriate under the facts of your particular situation.
Additionally, Medicaid “may waive the disqualification if the disqualification would create an undue hardship on the [Medicaid applicant].” OAR 461-140-0300(3). Elder law attorneys with little experience with Medicaid eligibility may not be advocating vigorously enough for their clients. Specifically, attorneys may not be filing Administrative Hearing Requests often enough after Medicaid denies eligibility based upon transfers of assets. Just because one attorney has told you that a particular transfer made within the sixty month “look back period” will be a bar to Medicaid eligibility, this does not mean that the Medicaid eligibility worker and a reviewing case manager at the application level, and the Administrative Law Judge at the hearing level, will agree with that opinion.
Miscellaneous Selling the HomeSelling a home before qualifying for Medicaid may significantly affect a Medicaid applicant’s eligibility and finances. Get legal advice about the timing of selling a home and Medicaid eligibility before putting the home on the market.
Medicaid Rules Vary from State to State Medicaid programs are joint federal and state programs. This means that some of the eligibility rules vary from state to state. Arizona does things differently than Oregon. If you Google Medicaid, you may receive conflicting information because you are retrieving information from multiple states’ Medicaid programs.
Medicaid Rules Change Frequently If you had a previous experience helping someone qualify for Medicaid in Oregon, don’t assume that the rules that applied then will be the same as the rules that apply now. If you are researching Oregon Medicaid eligibility rules now, but plan on not applying yet, the rules you come across now may have changed by the time you begin an Oregon Medicaid application.
If this is your situation, do not give up hope. There are exceptions to the gifting rule. Also, the screener or case manager assigned to your application may use their discretion and decide that imposing a penalty period is not appropriate under the facts of your particular situation.
Additionally, Medicaid “may waive the disqualification if the disqualification would create an undue hardship on the [Medicaid applicant].” OAR 461-140-0300(3). Elder law attorneys with little experience with Medicaid eligibility may not be advocating vigorously enough for their clients. Specifically, attorneys may not be filing Administrative Hearing Requests often enough after Medicaid denies eligibility based upon transfers of assets. Just because one attorney has told you that a particular transfer made within the sixty month “look back period” will be a bar to Medicaid eligibility, this does not mean that the Medicaid eligibility worker and a reviewing case manager at the application level, and the Administrative Law Judge at the hearing level, will agree with that opinion.
Miscellaneous Selling the HomeSelling a home before qualifying for Medicaid may significantly affect a Medicaid applicant’s eligibility and finances. Get legal advice about the timing of selling a home and Medicaid eligibility before putting the home on the market.
Medicaid Rules Vary from State to State Medicaid programs are joint federal and state programs. This means that some of the eligibility rules vary from state to state. Arizona does things differently than Oregon. If you Google Medicaid, you may receive conflicting information because you are retrieving information from multiple states’ Medicaid programs.
Medicaid Rules Change Frequently If you had a previous experience helping someone qualify for Medicaid in Oregon, don’t assume that the rules that applied then will be the same as the rules that apply now. If you are researching Oregon Medicaid eligibility rules now, but plan on not applying yet, the rules you come across now may have changed by the time you begin an Oregon Medicaid application.
Attorney Kristianne Cox's Flat Fee Legal Services Package
Private Medicaid eligibility attorney Kristianne Cox offers a flat fee package of legal services related to applying for the Oregon Medicaid for Long-Term Care Services program. This package of legal services is for those who want to delegate most of the time-consuming work of the Medicaid application process to an attorney who is familiar with the Oregon Administrative Rules governing eligibility for this Medicaid program.
The “Delegation” Package This option is for people who want to delegate to Medicaid eligibility attorney Kristianne Cox most of the time-consuming Medicaid application process, including follow-up communications with Medicaid employees. Kristianne will have you complete the Medicaid “Authorized Representative” form, which allows the Medicaid eligibility workers, the Medicaid case manager(s) and other Medicaid employees to communicate with her rather than you for most but not all purposes. You would still sign the Medicaid application attesting that the information it contains is accurate and agree to update the information with Medicaid upon discovering new information or upon a change in any provided information.
The “Delegation” Package This option is for people who want to delegate to Medicaid eligibility attorney Kristianne Cox most of the time-consuming Medicaid application process, including follow-up communications with Medicaid employees. Kristianne will have you complete the Medicaid “Authorized Representative” form, which allows the Medicaid eligibility workers, the Medicaid case manager(s) and other Medicaid employees to communicate with her rather than you for most but not all purposes. You would still sign the Medicaid application attesting that the information it contains is accurate and agree to update the information with Medicaid upon discovering new information or upon a change in any provided information.
If you would like to discuss hiring attorney Kristianne Cox, please contact her through the blue "Send Message" button on this website. Please include only general background information in your message. Do not include confidential information in your message.
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