Medicaid Applicant Who Reapplied Instead of Appealing Is Not Entitled to Retroactive Benefits

Vermont's highest court rules that a Medicaid applicant who finally qualified for benefits after applying and reapplying five times instead of appealing her original denial is not entitled to benefits retroactive to her first application. In re Landry (Vt., No. 13-452, Jan. 9, 2015).

Bernice Landry entered a nursing home, and in January 2011 her daughter submitted an application for Medicaid benefits retroactive to October 2010. The state denied the application because Ms. Landry's daughter failed to provide additional requested information. The denial notice stated that Ms. Landry could appeal or reapply at any time. Ms. Landry's daughter reapplied for benefits in June 2011. Again, Ms. Landry's daughter failed to provide additional information and the application was denied. The daughter reapplied twice more and both times the state denied the application. Finally, Ms. Landry's son filed an application for benefits on her behalf in February 2012 that included the requested information.

The state granted benefits to Ms. Landry, retroactive to November 2011. Ms. Landry appealed, arguing that benefits should be retroactive to the initial application. After a hearing, the human services board granted benefits retroactive to October 2010 for reasons of equitable estoppel, stating that Ms. Landry's daughter could reasonably be confused by the notice that informed her of her right to reapply at any time. The state reversed the board's decision, and Ms. Landry appealed to court.  

The Vermont Supreme Court affirms the state's decision, holding equitable estoppel does not apply and Ms. Landry is not entitled to benefits retroactive to the date of her original application. According to the court, to conclude that "the daughter’s reliance on her mistaken understanding was 'reasonable,' we must ignore her own admissions of failure to respond in any manner, and must assign legal insignificance to the explicit notice that if she disagreed with the [state's] determination, she must appeal that determination."

For the full text of this decision, go to: https://info.libraries.vermont.gov/supct/current/op2013-452.html

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