EPISODE 13- Medicaid Denied? What to Know & How to Win Your Appeal

Getting denied for Medicaid can feel like a dead end—but it doesn’t have to be.

In this episode, Jamie Callahan sits down with Maria Kain of Abundant Life Care Management to break down the real reasons why so many seniors are denied Medicaid—and how to successfully qualify or fight an appeal.

They discuss:

• Why so many seniors disqualify themselves during the Medicaid screening
• The key mistakes families make when applying
• How Maria's functional assessments reveal the real level of care needed
• What to expect during the Medicaid application or appeal process
• Powerful support available for spouses and families
• Why Oregon is one of the few states with Medicaid-funded assisted living

Whether you're helping a loved one apply—or reeling from a denial—this episode offers real solutions and guidance.

📞 Have questions? Call Team Senior at (541) 295-8230.

Transcript

Jamie: Hi, this is Jamie Callahan with the Team Senior Podcast. Our goal is to simplify aging. Society grooms us to plan for retirement, but what about life beyond retirement, where the rubber meets the road? Perhaps you've had a stroke or you've been diagnosed with cancer, or maybe you're forgetting things and now you have dementia.

That's our area of expertise and we are here to share our insight. And now the Team Senior podcast.

Jamie: Hi, this is Jamie Callahan and we have a guest in the studio again today. Her name is Marya, and I'm gonna let her tell you a little bit about herself before we get started.

Marya: Yeah, so my name is Marya Kane.

I'm the owner of Abundant Life Care Management and have been doing this work for over 47—almost 47 years I should say. And my master's is in exercise physiology with a minor in psych. Bachelor's in both. I'm additionally accredited as a certified care manager and a certified behavior consultant.

Jamie: Pretty impressive, my goodness. I'm not sure I even knew that. So today we're gonna talk specifically with Marya. She's been in the studio. She's gonna likely be in the studio several times again. We're gonna talk a little bit about Medicaid qualifications because this is an area where she can truly help to move the dial, whether it's an initial screening and assessment or an appeal that we're fighting.

And part of the reason is that when the Department of Human Services comes to do an assessment, they have a very limited amount of time that they're spending with the family and they're asking very pointed questions around what can you do for yourself? And then also, looking at whether or not dementia is really in play.

And unfortunately what we know of this generation—folks that are getting screened for Medicaid—is that their knee jerk response is to say that they can do everything. Because they want to appear to be wildly independent, even though we know—whether it's the person that's referring them to DHS or their adult child—we know that they can't do those things. But unfortunately, Medicaid is always in this position of having to decide whether or not they really need those Medicaid funds. And I feel personally that their knee jerk response is to deny Medicaid in most cases, where somebody even looks and smells like they can be independent.

Jamie: So Marya, when it comes to Medicaid eligibility, how do you help families navigate that application process?

Marya: You bring up some really good points. People tend to disqualify themselves because they want to impress the person that's interviewing them and asking those questions, and that would be a normal thing that we would want to do. However, it doesn't work to get them qualified. And so what I do is I first go in and I do what I call a functional assessment, where I look through all the criterion that Medicaid would be questioning them about and I really dig in deep. I have them show me how they do things. I walk through their house. I see that they're probably not showering because there's a lot of cobwebs in the shower, and really get in there to think, what does this really look like? Sometimes I'll have them demonstrate, sometimes I'll have them show me something like in the now moment. And I also ask—if they have a family member there—I will say, so do you set up their clothes? What is it if they don't have their clothes ready? Do they just put on the same clothes that they wore yesterday? Do they sometimes have their clothes in the wrong layers, like the underwear on top? What's really happening? Because we're gonna be able to use all that information to help them get qualified.

Jamie: Absolutely. Especially in those cases of dementia, right? So while somebody can appear to be physically healthy, if you're not spending enough time with the individual, you may not see that they have some cognitive issues. How much time do you spend with a family when you're providing the service for Medicaid qualifications?

Marya: Try to make it really as efficient as possible, but I do like to go through the doctor's records, get an idea of what diagnoses we're looking at, get an idea of are there even things in their instruction list of what they're supposed to be doing. Are they doing their nebulizer three times a day? Are they getting their eye drops in correctly? Oh, those dusty eye drop bottles that are over there—those are the ones we're supposed to be using? Try to get a real good sense of what's actually happening. And I have a method that I type everything up with, and then I like to be there when the interviewer comes. I also like to send my information ahead of time so that it can be as gentle and kind to the person and as respectful as possible. And have the family member—if they're there—not have to be in that awkward position of interrupting their loved one to say, "Dad, remember this?" "Oh, you fell yesterday." "I did?" Not have to do that.

Jamie: That's such an excellent—we have streamlined, yeah. It really takes the burden off the family to prove that mom or dad needs care when you're there to help substantiate what they need.

Marya: And I can be very specific and speak the same language.

Jamie: So it sounds like if you were gonna do a screening for the purpose of someone applying for Medicaid, you would meet with them several times. You would write a report that's then provided to the person that's going to do the resource assessment or the enrollment assessment for Medicaid.

Marya: Correct.

Jamie: Okay. What types of information, other than laying eyes on the individual, you've said that you refer or you review doctors' orders or doctor's notes. What else do you look at?

Marya: I also look at—I always like to do at least one of the memory screening tools, dementia screening. I also like to get an idea if there's depression going on, because that will also inform those activities of daily living. And I really just try to get a really good sense of what's happening and then I can speak to what is that Medicaid money gonna go to? This caregiver is gonna do these things specifically to help this person be successful. Because this is where they kinda hit the wall in their abilities.

Jamie: Sure. And we oftentimes tell people that when somebody is coming to do the screening for Medicaid, that we wanna think about our loved one on their worst day.

Marya: Absolutely.

Jamie: So while the screener's there, they might be upright and pretty capable that day. We all have those days, right?

Marya: I say that all the time. When I get up in the morning, what version of myself am I gonna be that day? Like really enthusiastic and energetic and capable, or just tired. In the landscape of where we work, we know that families many times have days where they're barely capable of doing anything. And so I feel like that has to be conveyed to the person that's doing the screening. We really wanna project what this individual looks like on their worst day. 'Cause that is the day that nobody's gonna be there and they can't get anything to eat because they can't get out of bed.

Marya: Two stories are popping up into my brain. One is, I had a gentleman that he got disqualified the first time because he could tell a great story about what his daily routine looked like. And the truth was he did not get out of bed. And he had his whole story about how he went down to Big Al's and had a hamburger for lunch and none of that was happening. And I also worked with a lady who told the same story and also disqualified herself. "I get outta bed every morning, I get dressed. It's no problem. I have some caregivers that come and help me make an evening meal because it's hard for my oxygen cord to make it that far, and it's hard for me to make it." The truth was when the first time I went to see her, I noticed something—some kind of something—on the back of her head. And she had actually fainted that morning and fallen on the back of her head and had a little goose egg there. And actually it needed some medical attention, but she wasn't gonna say anything about that.

Marya: And it was because she was so oxygen deficient that just getting up in the morning was often not successful. She often would get up and fall or faint and had a bump of bumps and bruises on her. So clearly needed some assistance, but her story was, "I'm fine. I can get myself out of bed."

Jamie: We hear that all the time.

Marya: Yeah, all the time. And sometimes they are trying so hard to project this very high level of independence. And it's because they want to remain independent.

Jamie: Absolutely. But I think ultimately, when we look at Medicaid, Medicaid is such an amazing benefit. In Oregon, we're one of three states that provides the opportunity for Medicaid to pay for someone to move into assisted living. Most states, that is really only true if you're gonna be moving into skilled nursing. So you're like end of life before you can qualify in essentially every other state. It's Oregon, Washington, and Florida that have this benefit. But in order for you to be able to move into assisted living and have Medicaid be your pay source, Medicaid has to substantiate that you deserve to receive those funds.

Marya: And that you have a real need.

Jamie: Yes. That you have a real need. So when we look at—we've talked about projecting yourself as being too independent and capable, and that's almost surely going to get you a denial for Medicaid. What are some other mistakes or pitfalls that families face and how can you help them?

Marya: I think that's the biggest. I work with somebody that helps them qualify for the financial part. I don't really do that part. I know some of the things, and I can give a little bit of guidance, but prefer to do that with a professional—that is their specialty.

Jamie: Yeah. And I would say too, in spousal situations, it's a really common misconception that spouses will keep their loved one at home for longer than they should, exhausting themselves as the caregiver. Because they don't want to deplete their own financial resources. But Oregon too—it's this area where this organization has found kind of a loophole or so to speak, where we can help spouses—for the person that requires care—qualify for Medicaid. We don't do that. Marya doesn't do that either, but we do work with the same person that helps individuals get their spouse that requires care on Medicaid with allowing the spouse that doesn't require care—often referred to as the well spouse—to keep the house without a lien against it, right? To keep a substantial amount of money and to keep a primary vehicle. And that's something that is also not usually disclosed by the Department of Human Services, but we certainly know how to help families get connected to that service. And it's just an area again where we could talk all day long and try to tell you everything that we know, but when you are in that place and you need that help, the likelihood of you remembering all the details—what we always just tell people is call. Marya is fabulous in this area.

She owns Abundant Life. Team Senior has all or many of the same resources. We work with families collectively all the time. So if there's one last thing you would want people to know about how you can help them qualify for Medicaid—'cause it is so important. I get those calls probably every other day and—crazy—but sometimes multiple times in one day where a family will call and say—they'll tell me all the things that are wrong with their loved one. That's a bad word to use—but all the areas that their loved one needs assistance. And then they will also say, "We just went through the Medicaid assessment and we got denied, and now we don't know what to do." So my understanding is you can also help them fight appeals. But as we close this podcast here, I really want folks to understand how, if you are questioning whether or not your loved one is going to get approved, or you have already been denied Medicaid, please reach out to us so we can connect you with Marya, or reach out to Marya directly. Tell us more about how you help people with that.

Marya: So when I first come meet with a family, there's no charge for that. I just want to make sure—get a lay of the land. You guys meet me and it gives us an opportunity to make sure we're gonna be a match and be able to meet your needs. And then from there, I really like to do that deep dive. And what we find is that when people get help, they're actually more independent and more able to do all those things that matter to them in their life. And we can take a tremendous burden off of the family to prove that that person is eligible to get that help.

Jamie: Yeah. It is so important. Like I said, we're very fortunate to live in Oregon where we have this available to us. Marya, thank you so much for your time. I really appreciate it.

Marya: Thank you for having me.

Jamie: Yeah, absolutely. Why don't you tell folks a little bit about how they can reach you?

Marya: My name is Marya, M-A-R-Y-A, Kane, K-A-I-N. I can be reached at Abundant Life, (541) 797-2000. I can also be reached at marya@abundantlife.team.

Jamie: Abundant Life Team—Marya at Abundant Life Team.

Marya: I always still want to say .com.

Jamie: Everybody wants to say .com. And I would also just encourage you that if for any reason you have questions about what she can do for you, or you want to reach out to us first, we're always so happy to weather that first incoming phone call and get you connected. I can't tell you—this is tremendous.

It is a huge opportunity for folks that especially have been denied Medicaid to utilize the service that she provides here. Because if it's my understanding, you haven't lost an appeal for somebody that you felt you could fight an appeal for.

Marya: Knock on wood.

Jamie: I know. Knock on wood for sure. So that's huge, right? This is a big difference, right? If you have an income of $1,600 a month and this state has come in—or the Department of Human Services has come in—and deemed you as being capable, but you need assisted living and it's gonna be $6,000 a month. Medicaid will pay for you to move to assisted living.

Marya: Yeah. If you need to move to assisted living, it's life changing.

Jamie: It is life changing. A whole new lease on life.

Marya: Absolutely.

Jamie: And Marya can help you fight that fight. She's gonna be your warrior. So thank you so much, Marya, and thank you everybody for listening. And until next time, thank you for listening to the Team Senior podcast.

We're here every week sharing new and relevant information. Remember that we're just a phone call away. Team Senior can be reached at (541) 295-8230. Again, (541) 295-8230. Until next time, this is Jamie Callahan.