Understanding Medicaid Estate Claims in Pennsylvania

Disclaimer: This article is for informational purposes only and does not constitute legal advice.

Detailed Answer

1. Overview of Pennsylvania Medicaid Estate Recovery

Pennsylvania participates in the federal Medicaid Estate Recovery Program under 42 U.S.C. § 1396p(b). The state implements recovery through the Department of Human Services (DHS) as outlined in 55 Pa. Code § 1184.21 and follows claim procedures in 55 Pa. Code § 1184.27. DHS may file a claim against the estate of a deceased Medicaid recipient for benefits paid after age 55.

2. Requesting Claim Documentation

To obtain your inherited estate’s Medicaid claim file, follow these steps:

1. Contact the county assistance office or DHS estate recovery unit. Request a complete claim package, including notices, supporting records, and calculation worksheets.
2. If DHS does not voluntarily provide records, submit a Pennsylvania Right-to-Know Law request under 65 P.S. § 67.101. Specify the estate recovery file by date and recipient’s name.
3. Allow up to 30 days for DHS to respond. You may appeal denials to the Office of Open Records.

3. Reviewing and Interpreting the Documentation

Once you receive the claim package:

• Verify the recipient’s identity, dates of service and amounts paid.
• Match payment dates to the critical period after the recipient turned 55.
• Check that DHS followed notice requirements under 55 Pa. Code § 1184.23, such as issuing a written notice of claim within 60 days of filing.
• Review calculation worksheets for accuracy in expense offsets (e.g., funeral expenses).

4. Challenging or Appealing the Claim

If you dispute the claim amount or procedure, you can:

• Request an administrative hearing. File within 30 days of the notice under the appeals process listed on the DHS Hearing Procedures page.
• Submit evidence of exempt assets, proof of undue hardship, or errors in calculations.
• Consider consulting an attorney experienced in elder law or estate matters for complex disputes.

Helpful Hints

• Keep records of all correspondence and deadlines.
• Review the original Medicaid eligibility files for baseline data.
• Prepare clear summaries of disputed items before a hearing.
• Explore fee waivers if estate assets are limited under the hardship provision.
• Consider mediation options with DHS before formal appeals.