516 RETROACTIVE MEDICAID

516 RETROACTIVE MEDICAID

Retroactive Medicaid eligibility is available when there is an unpaid medical bill for a service provided within three full months immediately before the month of application providing the individual meets all the eligibility criteria in the retroactive month requested. An applicant does not need to be eligible in the month of application (or current month) to be eligible for one or more months of Retroactive Medicaid. An applicant or recipient may ask for Retroactive Medicaid coverage at any time.

The individual requesting Retroactive Medicaid must meet all of the requirements for the Medicaid category, both financial and non-financial.

An individual can request Retroactive Medicaid at any time, even if they have been denied previously for failing to provide requested verification. The ET Eligibility Technician can determine eligibility for Retroactive Medicaid for the three months prior to any application for Medicaid.

The date of application, rather than the date of the eligibility determination, establishes the beginning of the three-month retroactive period. Eligibility for a retroactive month cannot be assumed based on current month eligibility. Determine eligibility for each month separately using the eligibility rules in effect for that month.

The ET Eligibility Technician must review the application for request of retroactive Medicaid coverage and accept and document the applicant's statement of medical need.

Retroactive Medicaid is determined using:

Eligibility criteria for the category of Medicaid;

Actual gross income received in each month;

Adjusted net income for self-employment (See APA MS 441-E ); and

Actual resources that were available as of the first moment of each month. Unless questionable, resources do not need to be verified. See Administrative Procedures Manual section 105-1C regarding verification of questionable information.

Example: Carolyn applies for Medicaid coverage in June. The caseworker determines that Carolyn was eligible for retroactive Medicaid coverage in March and April, but not in May or June. Any services received in March and April that have not already been paid for may be eligible for Medicaid coverage.

Deceased Applicants -- Application for Retroactive Medicaid coverage may be made on behalf of a deceased person. Payment will be made for covered services rendered to the deceased person during each month the person was eligible for Medicaid during the three month period. However, Medicaid does not pay transportation expenses for recipients who are deceased.

Medicaid Coverage During Retroactive Period -- Individuals eligible for Retroactive Medicaid are eligible for the same amount and scope of Medicaid services as was available to other Medicaid recipients during that time period. Coverage of services that normally require prior authorization are not automatically denied due to lack of approval prior to receipt of services during the retroactive eligibility period.

Only Unpaid Medical Bills -- Medicaid will only pay enrolled providers for unpaid medical claims for covered Medicaid services during the three-month retroactive period. Medicaid will not reimburse a recipient for medical services received during the retroactive period that have already been paid.

When an individual is found eligible for Retroactive Medicaid, the individual must provide evidence of this eligibility to their medical provider. Inform the recipient to give a copy of the retroactive Medicaid approval notice to the health care provider to assure that any retroactive claim is processed appropriately. The provider can then attach a copy to the claim before submitting it for payment. The individual remains liable for the unpaid medical bills until the provider has been given this evidence of eligibility and agrees to accept payment by billing Medicaid for this service.

Previous Section Next Section MC #68 (04/25)