827           RETROACTIVE MEDICAID ELIGIBILITY

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 individual may ask for Retroactive Medicaid coverage at any time.

Retroactive Medicaid eligibility can be determined, even if there are not any unpaid medical bills when determining Transitional Medicaid (see section 828-2 G) and Post Medicaid - Increased Spousal Support (see section 832).

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 caseworker can determine eligibility for Retroactive Medicaid for the three months prior to any application for Medicaid.

Retroactive Medicaid may also be available to an individual who is added to a case (e.g., child returns home).   

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.

Example:

Tony applies for Medicaid coverage in June. The caseworker determines he is eligible for Retroactive Medicaid coverage in March and April, but not in May. Any services covered by Medicaid that he received in March and April that have not been paid for can be covered by Medicaid.

The caseworker 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:

1)  Eligibility criteria for the category of Medicaid, except for the development of income. An individual cannot develop income for months already passed, such as for unemployment benefits.

2)  Actual income received in each month and for self-employment, actual adjusted gross income; and

Note:

Refer to Addendum 3 regarding PFDPermanent Fund Dividend income. Use the countable monthly PFDPermanent Fund Dividend amount in the month of determination for Retroactive Medicaid.

3)  Actual allowable income deductions.

Note:

Eligibility for retroactive Medicaid exists if the individual received Medicaid covered services during the months requested and would have been eligible for Medicaid at the time they received services if they had applied. 

If DOLDepartment of Labor and Workforce Development shows all of the individual's known income sources and the total quarterly income from these sources is less than the monthly income limit for the individual, do not deny request for retroactive Medicaid without reviewing the situation with your supervisor to ensure that we are not denying retroactive Medicaid to someone who is eligible. 

Example 1:

An individual applies for Medicaid 07/05/21 and requests retroactive Medicaid for 04/21, 05/21, and 06/21. The client reports that his only income is part-time employment at Fred Meyer. The caseworker requests verification of his actual income from Fred Meyer for 04/21, 05/21, and 06/21. The client does not provide the required verification by the due date. Before denying the retroactive Medicaid for failure to provide, the caseworker checks SAM and fins that client's total 2nd quarter (April - June) wages reported to DOL is below the monthly income limit for his category and household size. Since DOL shows all the client's known income sources and the total quarterly income from these sources is less than the monthly income limit for the individual, the caseworker reviews the situation with their supervisor and they  determine that the individual is eligible for 04/21, 05/21, and 06/21 retroactive Medicaid. 

Example 2:

An individual applies for Medicaid 09/10/21 and requests retroactive Medicaid for 06/21, 07/21, and 08/21. The client reports that his only income is part-time employment at Fred Meyer. The caseworker requests verification of his actual income from Fred Meyer for 06/21, 07/21, and 08/21. The client does not provide the required verification by the due date. Before denying the retroactive Medicaid for failure to provide, the caseworker checks SAM and finds the client's total 2nd quarter (April - June) and 3rd quarter ( July - September) wages reported to DOL is above the monthly income limit for his category and household size. Although DOL shows all the client's known income sources, the months of retroactive Medicaid being requested isn't covered by one quarter so the case must total the income from both quarters. Since the total income from these sources is not less than the monthly income limit for the individual so the caseworker continues with the retroactive Medicaid denial for 06/21, 07/21, and 08/21.

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.