Medicaid Policy
Medicaid Policy
An individual must meet eligibility for each month of the retroactive period in which the individual wants coverage.
To receive coverage for a retroactive month, the individual must meet all of the eligibility criteria for that month. It does not matter if the individual is eligible for the month of application. Determine income and resources for a partial month of coverage the same way you do for a full month of coverage. Specific criteria defined in 711 may limit the date eligibility can begin in the retroactive period.
The individual must spend down to the Medicaid income limit for each retroactive month for which the individual wants coverage, if a spenddown is owed. This applies even when coverage starts after the first day of that month.
The individual only needs to pay the spenddown for those months during which he wants any days of retroactive coverage.
The cost of the medical expenses Medicaid may pay for a retroactive month must be more than the spenddown. Deduct health insurance premiums and medical bills not payable by Medicaid or a third party to reduce the spenddown amount.
If the individual receives medical services during the retroactive period or application month that Medicaid cannot pay, the bills are deductions from income.
If unpaid, they can be used in and after the month medical services were received.
If paid, they can be used through the end of the month in which they are paid in full.
If the individual receives medical services during the retroactive period or application month that Medicaid can pay, and that are after the benefit effective date, the bills are incurred bills.
Incurred bills that are unpaid can only be used in the month of services.
Paid bills incurred during the retroactive period or application month can be used in the month of service through the application month. (See sec. 461-5 on using medical bills.)
Nursing home and waiver members who incur bills during a penalty period for transfers or who cannot receive long-term care services because of substantial home equity cannot use the nursing home or waiver expenses to reduce their cost of care for any months, even if the bills remain unpaid. See sec. 463-3.
A Medicaid Work Incentive member must pay their MWI premium, if one is owed, for each month included in the retroactive period to receive coverage for any days in such month. The member pays only for the months during which he wants any days of retroactive Medicaid coverage.
Ineligible for Application Month. When an applicant will not be eligible for coverage in the application month, ask if the individual will need any retroactive coverage. If so, determine the eligibility for the retroactive period based on the current application date so as not to lose possible coverage dates. See Sec. 705-1 to decide when eligibility can start. If the individual wants coverage in months after the application month, deny the application month, and then use the same application to decide eligibility for the month after the application month and future months. The new application date is the first day of that month (because you had denied the original application month.)