Introduction: Max was in a skilled
nursing facility (SNF). The monthly cost was staggering–$20,000 per
month! Sara, Max’s wife, was worried–how would she afford the cost.
The SNF social worker told Sara that Medicare would pick up the
tab----but only for the first 100 days, and maybe not that long.
What did she mean by “maybe not that long?” The social worker
explained that as soon as Max stopped improving with the
rehabilitative treatment, Medicare would end and that they expected
that that would be within the next 2 weeks. But Max would still need
skilled care so he couldn’t return to the lower cost Assisted Living
Facility. In other words, the continuing care would still be
hovering around $15,000 per month for the long term.
Sara began to panic. Then Bob, her son, suggested she see an
attorney. The attorney recommended that Sara, on behalf of Max,
apply for Medi-Cal and VA benefits. There were a couple of twists
and turns to get them eligible and that took about 30 days. Once
that was completed the application for Medi-Cal and VA were filed.
The VA benefits were granted in about 1 month. That provided
approximately $2000 per month; but that was really only a drop in
the bucket. Medi-Cal was really what they were after. Given that
Max’s monthly income was only approximately $3000 per month, that
meant that Medi-Cal would pick up the almost $12,000 difference
($15,000 monthly SNF bill less the $3000 of Max’s income).
Fortunately, after filing for Medi-Cal and once Medicare stopped
paying, Sara only had to pay Max’s estimated “share of cost” (the
amount that Sara would have to pay if Medi-Cal were approved. $3000
was a lot better than $15,000! But then Sara received in the mail a
denial letter from Medi-Cal. The letter said that Sara (and her
attorney) had not cooperated in providing the requested information
to the Medi-Cal eligibility worker. How could that be, every time a
request was made, the necessary document was sent in?
what happens when VA or Medi-Cal denies your claim? Appeal is
the magic word. There are time limits to be dealt with so one must
read the denial letter carefully. With Medi-Cal it is generally 90
days, with a hearing within in about 45 days of your request. VA is
typically one year with everything being dealt with through the
mail, at least at the first stage. And in either case, if you don’t
already have an attorney, you probably want one, now. And note, I
said an attorney, not a non-attorney representative (authorized
representative for Medi-Cal or accredited agent for VA).
Why an attorney?Although the initial
application can often times be handled by a non-attorney
representative, appeals can get technical and usually require
citations to the actual statutes and regulations. Most non attorney
representatives, even those who actually know what they are doing,
do not have that type of knowledge and are not equipped to do this.
How long does it take?For the
VA, an appeal to a Decision Review Officer (a DRO is sort of a
senior case worker taking a new look at the file) generally takes
7-15 months to obtain a decision. If one is turned down at that
stage, then the next step is a formal appeal to the Board of
Veterans Appeals (BVA).
For Medi-Cal, as stated earlier, the hearing occurs rather rapidly
and a decision can be expected in about 90 days. If turned down at
that stage, an appeal to the local State Superior Court would be the
next step. Further, at least in San Diego County, before the
hearing, the county authorities actually comb through the case file
to determine whether they think they have a strong footing or not.
If not, they usually will withdraw the denial letter and start all
My experience VA: I have mixed
emotions about DRO reviews. We have had success on a number of cases
at this stage. But since it is rare to non existent to actually
speak to a live person on VA cases or DRO reviews, I can only say
that sometimes I feel that the DRO has done no better job of
understanding what the facts are and what law governs than the
initial case worker. In those situations, formal appeal to the BVA
is the appropriate remedy. An actual hearing is available. For all
appeals, the VA must approve all fees charged to the claimant. Up to
20% of back due benefits is presumed to be reasonable and over 33%
is presumed to be unreasonable.
My experience Medi-Cal: (Note
this applies to San Diego County, only) I have been very pleased
with the appeals process as to the speed of the process, and the
treatment by the Medi-Cal authorities during the appeal. It is
relatively rapid and the Medi-Cal authorities have expressed an
interest in “getting it right.” Attorney fees are not reviewed by
the Medi-Cal authorities.