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UPDATED: JUNE 2011

495.7

OTHER ELIGIBILITY REQUIREMENTS RETROACTIVE PERIOD

PAYMENT OF UNPAID MEDICAL BILLS

NOTE: Because Family Health Plus benefits do not begin until eligibility is determined AND enrollment in a plan has occurred, there is no payment of unpaid bills available under the FHPlus program during the three-month retroactive period. However, individuals who are otherwise eligible under the Medicaid spenddown program during the three-month retroactive period through the date of enrollment in a FHPlus plan may be reimbursed for paid expenses in excess of their Medicaid spenddown.

Payment is limited to Medicaid enrolled providers, at the Medicaid rate, after application of ALL third party reimbursement.

Agency Delay:

Payment may be made for unpaid bills that are:

• incurred beginning 45 days after the date of application and before the receipt of a CBIC card; or • incurred beginning 30 days after the date of application when the application includes a pregnant woman or child under the age of 19 and before the receipt of a CBIC card; or • incurred beginning 90 days after the date of application when the application is based on disability and before receipt of a CBIC card; and • medically necessary; • covered by the Medicaid Program ; • within Medicaid requirements for amount duration and scope; and • provided by Medicaid enrolled providers.

Agency Error:

Payment may be made for unpaid bills that are: • incurred from the date of the social services district’s incorrect determination until the date the applicant 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.

To obtain payment for bills incurred during the retroactive periods, the recipient must document income and resources, as appropriate, in order for eligibility to be determined for the appropriate retroactive period. Once eligibility has been determined, appropriate periods of eligibility are recorded in WMS to allow payment to Medicaid enrolled providers. (MRG)