Operations
Medicaid Pending in Nursing Homes (& What to Do)
Written by
ExaCare
Published on
May 2, 2025
A new resident enters your facility without confirmed Medicaid coverage; their application has been submitted but not yet rejected or accepted. Now, you're suddenly balancing care delivery with financial uncertainty.
The term for this in-between phase — Medicaid pending — shows up often in admissions paperwork. For Medicaid pending in nursing homes, it's critical to have internal systems in place to track applications, communicate with families, and avoid preventable reimbursement losses.
In this article, we’ll cover:
What Medicaid pending means and who it applies to
How Medicaid pending impacts nursing home billing and operations
What providers can do to reduce delays and manage risk
What does Medicaid pending mean?
Medicaid pending is a temporary status that applies after a Medicaid application has been submitted, but before it’s been approved or denied. It most often comes into play when an older adult is admitted to a nursing home and lacks the resources to pay privately.
In these cases, the facility agrees to provide care while the state reviews the application, with the expectation that Medicaid will ultimately approve coverage and reimburse the facility retroactively from the date of application.
However, this reimbursement is not guaranteed, and retroactive Medicaid is a separate process. While retroactive coverage can apply to services provided up to three months before the application was submitted, it only kicks in if the applicant can prove they met all eligibility requirements during that period.
This can create additional complexity, especially if documentation is missing or financial eligibility isn’t clear-cut. Delays in Medicaid approval are common:
Some of the most frequent issues include incomplete documentation, such as missing ID, income verification, or bank statements.
In other cases, financial red flags like recent large asset transfers or unclear ownership of assets can trigger further scrutiny.
For individuals who are above the Medicaid resource limit, the delay may be tied to an ongoing “spend-down” process, where applicants reduce their assets to meet the program’s financial eligibility requirements.
Medicaid pending status can apply to a range of residents, including first-time applicants entering long-term care, residents transferring from another facility, or those currently going through the asset spend-down process.
Regardless of the path, the result is the same: the facility is delivering care without confirmed payment, which carries financial risk and creates pressure to resolve applications quickly.
How long does Medicaid pending take?
Determining how long for Medicaid approval isn't straightforward. It depends on the state, the completeness of the application, and how quickly families can respond to follow-up requests.
While federal guidelines require Medicaid agencies to process applications within 45 days, actual timelines frequently extend well beyond that. State-by-state differences, local staffing levels, and the complexity of an individual’s financial situation can all affect how long approval takes.
In many cases, delays are caused by:
Incomplete or inaccurate paperwork
Lack of necessary financial records
Requests for additional documentation during verification
Applicants are typically responsible for paying their estimated share of the cost to the facility during this time. And importantly, they cannot be discharged simply because their Medicaid case is still pending.
To avoid extended delays and financial strain on your facility, it’s worth investing in a more proactive process. Implement these steps:
Begin gathering required documents before admission, whenever possible
Assign a staff member or team to track the status of each pending application
Maintain regular communication with Medicaid caseworkers and families
If you’re wondering what to do while waiting for Medicaid approval, the answer lies in staying proactive. Follow up regularly with caseworkers, keep documentation updated, and maintain open lines of communication with the resident’s family.
Who pays while Medicaid is pending?
While Medicaid is pending, the resident pays most of their income, and families may make interim payments, which Medicaid may later reimburse if approved.
During the Medicaid pending period, care is being delivered, but there’s no payment from Medicaid yet. This puts many facilities in a difficult position. Residents are typically required to contribute most of their monthly income toward their cost of care, keeping only a small Personal Needs Allowance.
In cases where the resident is married, part of their income may be allocated to the non-applicant spouse. This is known as the Monthly Maintenance Needs Allowance and can be as high as $3,948/month in 2025, depending on the state and household situation.
Some facilities ask families to sign guarantees or make interim payments during this time. While this may seem like a stopgap, it comes with risks. Payments from family members may not be reimbursed by Medicaid, and depending on how they’re handled, could even jeopardize the resident’s eligibility.
Facilities must tread carefully, as pressuring families for payment can create compliance issues and lead to tension.
If Medicaid is approved, the program will reimburse the facility retroactively from the date of application, minus the share of cost the resident was expected to pay. However, if the application is denied, the full cost of care becomes the responsibility of the applicant or their family, usually at the facility’s private pay rate.
Throughout the pending period, clear and consistent communication with families is essential. Facilities should explain what’s expected, what’s at risk, and how the process works, while avoiding language that implies payment is guaranteed.
It’s also worth reminding families that residents cannot be evicted for nonpayment while an application is pending, and they have the right to appeal if coverage is denied.
Financial impact on nursing homes
When a resident is admitted under pending status, the facility provides care without a guaranteed payer. This creates a growing accounts receivable (AR) balance and puts strain on monthly cash flow, particularly for facilities already operating on tight margins.
Many providers hesitate and weigh the financial risk before accepting Medicaid pending residents. This is especially true when prior denials or long processing times have created past losses. Over time, this caution can directly affect census and reduce overall occupancy.
Bed hold decisions become more complex as well.
While Medicaid may reimburse for temporary bed holds under specific conditions, this coverage typically only applies once a resident is deemed eligible.
During the pending period, providers often have to decide whether to reserve a bed without assurance of payment — adding another layer of financial risk.
Key financial pressures caused by Medicaid pending include:
Delayed or missed revenue, which can lead to cash shortages
Increased AR balances, particularly for long-pending or denied applications
Reduced census, when facilities limit admissions due to payment risk
Potential bad debt, especially when Medicaid is denied and families are unable to pay
What happens if Medicaid is denied after admission?
If Medicaid is denied after a resident has already been admitted, the facility becomes responsible for unpaid charges unless alternative payment can be arranged. This often results in significant bad debt, especially if the resident or their family cannot cover private pay rates.
Facilities may need to initiate collections or begin the discharge process, which requires advance notice, a safe discharge plan, and strict adherence to state and federal regulations.
Best practices for managing Medicaid pending
Best practices for managing Medicaid pending cases include starting Medicaid applications early, assigning a dedicated tracking team, using software to monitor cases, and keeping families informed.
This approach is proactive, organized, and reduces delays while protecting your facility from unnecessary risk.
Start the application process early
Begin the Medicaid application process as early as possible, ideally before admission, if the need for long-term care is anticipated. Even initiating a pre-screening or helping families gather essential documents ahead of time can shave weeks off the process.
Facilities that build Medicaid readiness into their admissions workflow tend to avoid last-minute scrambles, especially in states with long processing timelines.
Pro-tip: Consider offering a Medicaid checklist at referral or inquiry stage to get the process moving before a bed is even filled.
Assign a Medicaid liaison or tracking team
Having one person or a small team responsible for Medicaid applications can dramatically improve oversight. This person becomes the point of contact for caseworkers, families, and internal staff, ensuring nothing gets lost in the shuffle.
Assigning ownership also reduces the chances of missed follow-ups or expired documentation. To make this role more effective, give them access to dashboards or case tracking tools that help them manage multiple applications at different stages without relying solely on manual spreadsheets or emails.
Keep families informed and involved
Misunderstandings about Medicaid are common, and families often don't realize how the process affects both care and billing. Set expectations from day one, especially around required documents, processing delays, and interim payments, to help prevent conflict later.
Offer clear, written explanations of what “Medicaid pending” means, as well as next steps. Make sure families know who to contact for updates.
Some facilities even schedule weekly touchpoints with families of pending residents to keep everyone aligned.
Use software tools to track at-risk cases
Manual tracking can only go so far, especially in multi-facility groups or high-volume settings.
Software like ExaCare can help your admissions team stay ahead by using AI to review referral packets in real time and extract critical payer and clinical details.
When a referral includes incomplete insurance documentation or signals potential reimbursement risk, ExaCare flags it immediately, giving your team a clear heads-up on cases that may need closer attention.
Because ExaCare integrates with leading referral platforms and EHRs, all incoming referrals are centralized in one place. That means your team can make decisions faster, avoid toggling between systems, and stay organized as cases move from pending to approved.
Ensure regulatory compliance at every step
Your response to Medicaid pending cases must be as compliant as it is consistent. Residents cannot be discharged for nonpayment while a Medicaid application is pending, and any discharge due to denial must follow all state and federal guidelines, including notice periods, appeals, and safe discharge planning.
Build a simple checklist into your workflow to confirm that all legal requirements are met before initiating collections or transfers. When questions arise, stay in contact with ombudsman programs or legal counsel to help your team deal with complex situations while protecting both residents and the facility.
Frequently asked questions
Can a facility discharge a resident while Medicaid is pending?
No, a facility cannot discharge a resident solely because Medicaid is pending. Residents have the right to remain in the facility during the application process, and any discharge must follow federal and state regulations, including proper notice and care planning.
Who pays the bill during the waiting period?
During the Medicaid pending period, the resident is typically expected to pay their share of costs using most of their monthly income. Medicaid does not pay the facility until the application is approved.
Why is my Medicaid still pending?
Medicaid applications may remain pending due to missing documentation, incomplete financial records, or the need for further eligibility verification. Processing times also vary by state and can be delayed by high case volume or complex financial situations.
Does Medicaid cover retroactive care?
Yes, Medicaid can cover care retroactively for up to three months before the application date if the applicant was eligible during that time. This is separate from the Medicaid pending period, which starts after the application is submitted.
Can Medicaid pending affect bed availability?
Yes, some facilities may hesitate to admit residents under Medicaid pending status due to the financial risk. This can impact overall bed availability for applicants without confirmed coverage.
Can a family speed up the Medicaid application?
Families can help speed up the process by submitting complete and accurate documentation as early as possible, staying in communication with the caseworker, and responding quickly to any requests for additional information.
How ExaCare helps manage admissions
Getting through the financial uncertainty of Medicaid pending in nursing homes requires proactive coordination between admissions teams, Medicaid caseworkers, and family members.
Medicaid pending status can quietly destabilize even well-run operations, delaying revenue, straining staff, and making it harder to fill beds confidently. While facilities are expected to provide care during this uncertain period, they do so without financial guarantees.
That’s why it’s critical to build internal systems that track applications, keep families informed, and prevent cases from slipping through the cracks. Managing it well is not just about reimbursement, it's about protecting census, reducing risk, and maintaining operational stability.
That’s also where ExaCare comes in.
ExaCare transforms your admissions process by using AI to streamline referrals, automate document review, and help you make faster, more informed decisions. Our platform helps you modernize your operations while maintaining the quality of care your facility is known for.
Here’s what we offer:
AI-powered referral screener that reviews hospital packets in minutes, enabling quick and accurate admissions decisions
Centralized referral management that brings all your sources into one platform
Built-in analytics to help you track performance and optimize your referral relationships
A unified communication hub to streamline decision-making with colleagues
Ready to see how ExaCare can help your facility win more referrals? Talk with our team to learn more.
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Automatically identify and flag medicine costs and generate reimbursement arguments
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