Wrongful Denial:

We received a call from a woman whose husband was in a nursing home and his application for Medi-Cal was denied. After having us appointed as his “Authorized Representative” for Medi-Cal, we were able to speak with the Worker who denied the case and have the case transferred to the appropriate branch office. Her husband’s Medi-Cal was approved within the week.

Our Comment: The Medi-Cal process is complicated and there are many programs. Although this Medi-Cal Worker was irritated with me for stepping in, most Workers are caring people who simply make mistakes because they are new or are not aware of certain guidelines. Unfortunately this happens way too often. When it happens with us in the process, we are able to have the denial reversed and get the approval.

Misinterpretation of the Medi-Cal Guidelines:

We had four denials for the first month of nursing home care from one county. This county (as well as a few others) believed that “Long-Term Care Medi-Cal” did not apply for the first month of care. With this interpretation, our four married clients would only be able to have $3000 in total assets or they would be required to pay for the first month of care on their own. This would have cost one couple an additional $5400. We filed “Fair Hearings” and the Hearing Officer approved the cases without the hearing. The remaining two cases were approved after having the Workers’ supervisors contact the Hearing Officer.

Our Comments: Many counties have differing interpretations. But Medi-Cal is a State and Federal program. The rules are the rules. Because we knew the rules, our clients saved thousands.

Another Case Saved:

We had completed and submitted the redetermination packet (due every year to continue eligibility) for our clients who are married. The husband had some very serious health problems and needed Medi-Cal coverage. They were both retired and the wife had a 401K retirement plan that she was not touching because of her young age. The Medi-Cal worker explained over the telephone that she was going to deny the case because the wife had too many assets. After pointing her to the Medi-Cal document which listed her 401K as “Exempt” and asking her to speak with her supervisor, the Worker graciously thanked us for pointing that out to her and continued the case for another year.

Our Comment: Again, a very nice person who thought she was doing her job correctly. This case would have been discontinued without knowledgeable intervention.

A Common Story:

Since this case, we have taken on many denials and turned them around, usually by filing Fair Hearings. We received a call in July 2007 from a woman who made an application for Medi-Cal for her husband. The application was pending January approval. This lady provided every document requested by her Medi-Cal Workers. I say “Workers” because she never received approval and she was now on her third Worker. Upon taking the case, our client sent her Worker an Appointment of Representative form appointing THE LIGHT to represent them. This Worker did not respond to multiple telephone calls from our office. After calling the main line and requesting a supervisor and, again, reaching another voicemail, we finally received a call back from both the Worker and the “New Worker” who told me the case had been denied last month for failure to provide documents. We filed a Fair Hearing for failure to provide a written request for documents, failure to send a denial notice, and using the wrong asset limits in determining eligibility. The Worker stated that the applicant failed to request the correct program. Our response was that she was a layperson and would not know to request the “correct program.” The case was sent back to the last Worker to determine eligibility under the correct program and the case was approved retroactive to January. Since this case we have also handled her cousin’s case and then her mother’s, both referred because of the success of this case.

Our Comment: Our client almost was lost in the shuffle. She did not know her rights or the process. She also did not have the ability to pay for a nursing home for those eight months that she would have lost on her own at a cost exceeding $5000 per month. Especially now that California has cut their Medi-Cal staff by one-third and there is no access to call your Medi-Cal eligibility workers directly, we highly recommend no one navigate the Medi-Cal application process on their own. (See actual Medi-Cal study of a focus group of 92 “low-income” applications between May and July 2011 of which only 41 had approvals by September 2011, with only eight applications still pending. Thirty were denied coverage, four had moved, and nine could not be reached.) Case Study Link: Click Here To View Case Study There is no good reason for any denial with a “low income” applicant. The Light would have first analyzed and explained the benefits of a Medi-Cal approval to determine suitability and provided a care plan, if needed, and a quote for future services. If asked to continue, The Light would then properly position the assets, prepare the application, and follow the case to completion. We make sure all months applied for are approved, the “Share of Cost” is figured correctly, and proper notifications of changes are submitted to Medi-Cal over the next year. We have NEVER lost a case.

Carol Costa-Smith
Tel: (858) 751-0752 
Toll Free: (888) 413-3113 
Fax: (888) 308-9223 8250 
The Light for Seniors, Inc. 
dba Light Source Insurance Solutions
Vickers Street, Suite G, 
San Diego, CA 92111