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What is Retroactive Medicaid

Monday, July 27, 2020

Life can have its desirable and also undesirable surprises every day. Those undesired surprises can be severe injuries and illnesses that can leave you with expensive medical bills with no insurance coverage. 

If you have recently been approved for Medicaid, you may be eligible for retroactive Medicaid, which can relieve unnecessary stress that comes with paying for medical coverage. 

First let's break down some basic Medicaid information.

 

What is Medicaid?

 

Medicaid is a form of public health insurance in the United States that provides coverage for free or reduced prices for citizens with low household incomes. 1 in 5 Americans are covered by Medicaid, so it is a highly used form of health insurance. Medicaid beneficiaries tend to be people who can’t afford other health insurance plans.

 

While Medicaid, alongside Medicare, is governed by the CMS (Centers for Medicare & Medicaid Services), states have control as to how Medicaid is delivered to its residents. State agencies are given this freedom to administer Medicaid how they want due to Section 1115, which will be discussed later on.

 

What is covered by Medicaid?

 

Medicaid provides a variety of different services for different populations. Listed below are some of the services provided by Medicaid to various populations.

 

·       Low-income families: prenatal care and delivery costs, routine medical visits and specialized care for children, coverage for unexpected emergencies 

·       Disabled individuals: assisted care, in-home therapy, speech/occupational therapy, physician services, prescription drugs

·       Seniors (65 and older): nursing home care, personal care, and community-based care, Medicare beneficiary

 

Medicaid is beneficial for the elderly population as it provides them with coverage for long-term care that is not provided through Medicare.

 

What is retroactive Medicaid?

 

Retroactive Medicaid is a provision protected by federal law that ensures state Medicaid programs provide coverage to you, the beneficiary, at up to three months before their application date for unpaid medical bills. 

This is to help assist you with any unpaid medical expenses you may have before you became eligible or had applied to Medicaid.

 

Benefits of retroactive Medicaid are the following:

 

·       Relieves you (and loved ones) of the stresses that come with unpaid medical bills

·       Can be filed after you or a loved one perishes

·       A safety net for any unexpected illnesses or injuries

·       Pays for unpaid medical bills and services three months before the Medicaid application date

·       Possible reimbursement for unpaid medical bills

·       Helpful for those living in nursing homes or long-term care facilities

·       Prevents you from being reported to Credit Bureaus for unpaid medical bills

 

If you do not apply for retroactive Medicaid, you will not begin to receive Medicaid benefits until the date you applied, or the first day of the month when you applied. Some states may use the date that they received your application as the determining factor for your retroactive eligibility period.

 

Having retroactive Medicaid can be the ultimate stress reliever for you and your loved ones as medical bills can be troublesome to pay without health insurance coverage. Retroactive Medicaid provides a safety net in case of any unexpected illnesses or injuries you may run into while you don’t officially have Medicaid coverage.

 

You must meet all of the requirements to receive retroactive Medicaid, which is based on the normal guidelines for acceptance into the Medicaid program.  

 

Am I eligible for Retroactive Medicaid?

 

To receive acceptance for Retroactive Medicaid, you must meet the normal requirements for Medicaid eligibility. This includes meeting both financial and non-financial requirements for Medicaid. There is no specific requirement for getting retroactive eligibility, as long as you are accepted for Medicaid. These requirements must be met at least 3 months before your application date.

 

Any medical services that you have received during those 3 months must be services that Medicaid already covers. Medicaid will not pay for medical services that are not medically necessary for your health or not ordered by your physician.

 

Listed below are some of Medicaid eligibility requirements for different states:

 

·       Be a U.S. citizen or have qualified immigrant status

·       Have a Social Security number

·       Receive a low monthly income

·       Be a resident of the state you’re applying for Medicaid

·       Have limited resources

·       Are a child, adult, senior, and/or disabled

·       Pregnant

·       Have expensive medical bills

·       Reside in a nursing home

·       Receive SSI (Supplemental Security Income)

·       Foster home children

 

For the elderly population, there is an opportunity for them to receive waivers for any home and/or community-based services they receive under retroactive eligibility. Retroactive coverage can cover both one-time and recurring medical expenses.

 

There are different circumstances if you are applying for Medicaid due to pregnancy. For pregnant women, retroactive Medicaid will not be able to be established before the month of conception. However, Medicaid coverage will be provided if they were pregnant during the three-month retroactive eligibility period.

 

Eligibility requirements vary by state, so be sure to research the Medicaid guidelines specifically for your state. What retroactive eligibility is accepted in one state may not be what's available in your state. Visit the Medicaid website to look up your state’s retroactive eligibility requirements.

 

Be sure to verify that you meet your state’s Medicaid eligibility requirements before applying. Be aware that you can be denied health insurance and have to either file an appeal or re-apply. You must have Medicaid to reap the benefits of retroactive Medicaid.

 

What if the applicant is deceased?

 

As mentioned earlier, you can complete an application on behalf of a deceased individual. They will still receive payments for Medicaid-covered services during the three-month period in which they were eligible for retroactive Medicaid. Medicaid will not cover the expenses for transportation (such as funeral costs) for the deceased.

 

How do I request retroactive Medicaid?

 

Retroactive Medicaid can be requested at any time within the date of the application and the first year of Medicaid coverage. Find out the steps to getting retroactive Medicaid coverage below.

 

1)    Get an application: You can receive an application online by going to Medicaid.gov and searching for your state. You will then be redirected to your state’s Medicaid website where you can download the application.

2)    Complete the application: Once you have downloaded and printed the application, fill out the application in its entirety. Any dependents you have in your household that are over the age of 18 can submit applications on their own.

3)    Turn forms in person: State Medicaid agencies typically do not require you to submit your application in person, it is advised that you turn it in personally. You cannot send your application in through mail because you will need some original copies of certain documents.

4)    Remember appointments: Set reminders for your appointments with your state’s Medicaid office. If you fail to be present for your appointments or don’t provide documentation, your application can be delayed.

 

Pregnant women, women 60 days postpartum, and children up to age 19 (in certain states) are exempt from retroactive Medicaid requirements.

 

When applying for Retroactive Medicaid, there will be a request for you to verify your U.S. citizenship or alien status. This must be done to ensure your application is processed.

Assistance with applying for retroactive Medicaid

 

If you need assistance applying for retroactive eligibility or Medicaid, there are plenty of options you can choose from that are either free to the public or with private professionals that’ll charge a fee.

 

Medicaid planners can assist you with the application and planning your finances for the 90 days before the application. They help to ensure that you don’t make errors that can disqualify you for retroactive eligibility. 

 

Applying for retroactive Medicaid

 

Applying for retroactive Medicaid can vary depending on which state you are located in. Sometimes the process may be as simple as marking a checkbox on a Medicaid form or completing another addition form. Filling out the application is fairly simple to do but having all the required documents may be a hassle for some. Listed below are the documents that need to be filed with the retroactive Medicaid form.

 

·       Evidence of the medical condition

·       Documents detailing current finances

·       Evidence of functional need

 

 

 

 

 

How far back will Medicaid pay a claim?

 

As mentioned earlier, Retroactive Medicaid will provide coverage for medical services three months before the day you filed for Medicaid. This is typical but some states use Section 1115 waivers to adjust this federal provision.

 

Section 1115 (State Restrictions)

 

Despite retroactive eligibility being federally mandated, states have found ways to restrict it.

Section 1115 waivers allow states to flex how they use and operate Retroactive Medicaid for their residents. Under Section 1115, the Secretary of HHS (Department of Health & Human Services) allows states to use their Medicaid funds in ways not typically allowed under federal laws. States can test new approaches that are different from the federal provisions.

 

For example, Hawaii and Massachusetts have reduced their retroactive period from 3 months to 10 days of eligibility. Other states have a retroactive period from 1-30 days of eligibility.

 

Florida in 2019 limited retroactive eligibility to pregnant women and children under the age of 21, meaning that those living in nursing homes will no longer receive the retroactive benefits.

 

As of May 2019, the following states: Arizona, Arkansas, Indiana, New Hampshire, Massachusetts, New Mexico, Oklahoma, Utah, Maine, Kentucky, and Delaware have made moves to either eliminate or restrict retroactive eligibility.   

 

What will Medicaid cover retroactively?

 

There are many medical services that retroactive Medicaid will cover. Medicaid can often provide coverage for medical and care bills that you have already be paid. To receive coverage, your state Medicaid agency must deem your services to have been medically necessary for your health. Also, there are services that Medicaid covers that may require prior authorization, but with retroactive eligibility, some of those claims may not be denied.

 

View the list below to see what retroactive Medicaid covers in most circumstances.

 

·       Home health care

·       Doctor’s office visits

·       Nursing home care

·       Drug prescriptions

·       Non-emergency transportation for medical appointments

·       Medical equipment

·       Laboratory works (x-rays & imaging)

·       In-patient and out-patient hospital services

 

 

While most state Medicaid agencies will provide you with coverage for all three months, you can be deemed ineligible for one or two months, meaning you would have to pay for those remaining medical expenses on your own. Retroactive Medicaid is determined on a month to month basis. For example, you can receive retroactive eligibility for September and October, but not for November.

 

How does payment/reimbursement work?

 

You have been deemed eligible for retroactive Medicaid, now what? You will receive a document that shows that you received retroactive Medicaid. This document should be given to your healthcare provider(s) that you owe unpaid medical bills too. You can attach the approval to the claim and submit it to your provider so they can be paid for their services.

 

Healthcare providers often have a certain period in which they have to bill the state Medicaid agency. If they do not send the bill to the state within the period, they will not be paid. You should have received a Medicaid card in the mail in which you would also attach to the forms you give to your healthcare provider. If you haven’t received your Medicaid card yet, or it was never mailed to you, the time limit will not apply to you.

 

There are certain circumstances in which your state’s Medicaid agency may allow you to be reimbursed for any paid bills. With this, you would show your Medicaid to your healthcare provider and ask to have the money refunded and then bill Medicaid the remainder. It is to be noted that not every healthcare provider accepts Medicaid, so retroactive eligibility will not be beneficial in this case.

 

Remember, you are legally responsible for paying for any unpaid medical services you receive. This responsibility lasts until your retroactive eligibility is enacted and your healthcare provider is notified. Also, your healthcare provider must agree to send your medical bills to Medicaid.

 

Exceptions to reimbursements/payments

 

There are a few circumstances in which you may have to pay all or a partial amount of your medical bills. Here are the following situations:

 

·       If you are notified by your healthcare provider that they do not accept Medicaid, but you proceed to receive services.

·       If you agree in writing that you were informed that a service is not covered by Medicaid, you will have to pay.

·       If you are a part of an HMO (Health Maintenance Organization), you need to ask your primary care physician for a referral before being sent to a specialist physician. If you miss this step, you may end up paying for those services.

·       There are some situations in which you’ll have to pay a small copayment for some services you received.

 

If needed, you can always call your local state Medicaid agency office if you receive a bill from a healthcare provider.

 

Forms

 

Posted below are the forms that are associated with applying for retroactive Medicaid. These forms come from various state health departments and are being used as examples of what you can see if you decide to apply for retroactive Medicaid. To find the specific forms that pertain to your state Medicaid office, visit this website.

 

Form for Applying for Medicaid

 

If you haven't already, apply for Medicaid to see if you're eligible for coverage. Please refer to the above-mentioned requirements for Medicaid before applying. Most applicants apply online, but there is an option to get a paper application as well. Listed below is the Medicaid application for Alabama residents.

 

 

This form was created by the Alabama Medicaid Agency for Alabama residents that can be accessed here.

 

Request for retroactive Medicaid Coverage

 

With this form, you would apply for retroactive Medicaid. Completing this form will start the process of you obtaining retroactive coverage for up to three months before your Medicaid application date.

 

This is the form created by D.C. Department of Human Services for D.C. residents that can be accessed here. A Spanish version is available here.

 

Patient’s Request for Medical Payment (CMS 1490S)

 

This is a form you would submit to receive any form of reimbursement from Medicaid for any services or supplies you paid for. With the form, you would attach your bill and any other supporting documents.

 

This form was created by the Centers for Medicare & Medicaid Services (CMS) and can be viewed here.

 

Conclusion

 

Paying out of pocket expenses for medical services and care can be extremely exhausting and stressful for many. Luckily, there is an opportunity to receive coverage through retroactive Medicaid. Retroactive Medicaid is a great way to get your medical services paid for without having to pull out your wallet or get a reimbursement if you have already paid.

 

Be sure to do more research on retroactive Medicaid and contact your state’s agency to get more information on how you can apply.

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