5008           RETROACTIVE MEDICAID ELIGIBILITY

Retroactive Medicaid eligibility may be available to a Medicaid applicant who did not apply for assistance until after they received care, either because they were unaware of Medicaid or because the nature of their illness prevented the filing of an application.  

Retroactive 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.  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.

Note:

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).  See Sections 5005-2(B) and (C) to determine if a new application is required.  

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 caseworker must inform each applicant of the availability of retroactive Medicaid coverage.
 

• Ask the applicant if he or anyone in the household needs help paying for an unpaid medical bill during the retroactive period.
   

• Accept and document the applicant’s statement of medical need.

Retroactive Medicaid is determined using:

• Actual income received in each month;
   

• Adjusted gross income for self-employment based on the appropriate type (monthly, seasonal or annual) of self-employment.   (see Section 5164-1(C) for definitions and Section 5164-2 for budgeting methods); and

• Actual resources that were available in each month. Unless questionable, resources do not need to be verified. See Administrative Procedures manual section 105-1C regarding questionable information.

Example:

An individual applies for Medicaid coverage in June.  The caseworker determines that the individual was eligible for retroactive Medicaid coverage in March and April, but not in May.  Any services covered by Medicaid that the individual received in March and April that have not been paid for can be covered by Medicaid.

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.

Pregnant Woman Medicaid -- Eligibility may be granted retroactively.  The retro-month determines the first month of eligibility and continues forward throughout the pregnancy.  See Section 5310-B.

Postpartum Medicaid -- Eligibility may not be granted retroactively.  The woman must be receiving Medicaid on the date that her pregnancy terminates in order to receive postpartum coverage.

State Residency Required -- If an applicant has recently moved to Alaska, and did not reside in the state during the three-month retroactive period, the responsibility for medical coverage rests with the previous state of residence.  Application may be made in Alaska for any month (during the three-month period) in which the individual did reside in the state, as long as that person was not receiving benefits from another state during the same time period.

Transitional Medicaid -- For the purposes of determining Transitional Medicaid eligibility, retroactive Medicaid can be used to determine whether a current Medicaid recipient in another eligibility category or a new applicant would have been eligible for Family Medicaid in three of the last six months.  For more details see Section 5220.