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UPDATED: JUNE 2011

495.3

OTHER ELIGIBILITY REQUIREMENTS RETROACTIVE ELIGIBILITY PERIOD

REIMBURSEMENT OF PAID MEDICAL BILLS

plan may be reimbursed for paid expenses in excess of their Medicaid spenddown.

Retroactive Period:

Reimbursement may be made to a Medicaid eligible individual or his/her representative for paid bills that are: • incurred during the retroactive eligibility period, which begins on the first day of the third month prior to the month in which the individual applied for Medicaid and ends on the date the individual applies for Medicaid; • medically necessary; • covered by the Medicaid Program; • within Medicaid requirements for amount duration and scope; and, • received from providers lawfully permitted under State law or regulation to provide the care, services or supplies for which the recipient is requesting reimbursement and who has not be excluded by the Medicaid Program.

Post-Retroactive Period:

Reimbursement may be made to a Medicaid eligible individual or his/her representative for paid bills that are: • incurred during the post-retroactive eligibility period, which begins on the date of application and ends on the date the individual receives a CBIC card; • medically necessary; • covered by the Medicaid Program ; • within Medicaid requirements for amount duration and scope; and, • provided by Medicaid enrolled providers.

NOTE: For new SSI recipients, reimbursement for paid medical expenses beginning three months prior to the month of application and ending on the day the recipient receives the “Dear SSI Beneficiary” letter must NOT be limited to expenses incurred from providers enrolled in the Medicaid program.

Agency Delay:

Reimbursement may be made to a Medicaid eligible individual or his/her representative for bills that are paid as a result of an LDDS’s delay and are: (MRG)