Medicaid Policy
Medicaid Policy
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Individuals may request retroactive coverage after an application is approved, when they did not request it originally.
The application must be approved and the individual must receive benefits in at least one month. The individual must meet the spenddown or MWI premium if one is owed. The retroactive period is based on the application date.
If the application was denied, the person cannot later ask for retroactive coverage. She would need to file a new application, which would establish a new retroactive period.
If the applicant will not be eligible for the application month, decide if the applicant needs retroactive coverage. If so, determine eligibility for the retroactive period so she does not lose the option to receive coverage for those months. Then deny the application month. If the same application form is used to determine eligibility for the following month, the first day of that month becomes a new application date. See sec. 711.
If the individual had been determined eligible for a retroactive month when she applied, but then failed to meet the spenddown or MWI premium owed for such month, she cannot later request coverage for that retroactive month. However, she can reapply. If the month she wants is within the new retroactive period, she could receive coverage for that month based on the new application.
If eligibility was denied for one or more months of the retroactive period, the individual cannot later request coverage for those retroactive months based on the initial application. The individual may file a fair hearing request within the allowed time-frame if he disagrees with the denial. The individual may also reapply. (See #4 below)
There is no deadline for requesting the retroactive coverage on an approved application when the individual has not asked for coverage for that retroactive period before. However, if any of the months you are approving are more than 12 months ago, some medical bills may not be paid. Follow the steps outlined in 705-4.
Appropriate eligibility rules must be applied for the retroactive month. When the individual requests coverage for a month before January, 2014, eligibility cannot be determined using MAGI-based methods.
Do not grant coverage for the retroactive period if the individual did not request it at the time of application and the application was denied, unless the worker finds eligibility was denied in error. The error must be discovered within 12 months of when the error was made. (See sec. 707)
If eligibility was denied in error, redetermine eligibility for the application month.
If the individual is eligible and meets any spenddown or MWI premium that is owed, also determine eligibility for the retroactive period the individual is now asking for, based on that date of application. (Sec. 703-2) Follow the policy in 705-3.
If the agency discovers the error more than 12 months after it was made, do not make any change.
A denied application does not prevent a individual from reapplying for some of the same retroactive coverage period. Determine the new retroactive period based on the new date of application. Do not go back more than three months before the new month of application. The benefit effective date, based on the new application, would also be subject to the policy in 711 and 705-1.
If an applicant is approved for coverage for any part of a month in the retroactive period, but owes a spenddown or MWI premium, he must meet the spenddown or pay the MWI premium to receive coverage. If he does not meet the spenddown or the premium, he cannot request coverage later for that month based on the same application. He may reapply and request coverage for part or all of that month only if it is within the retroactive period based on the new date of application. Workers must make a new determination of eligibility. The applicant must continue to meet the eligibility criteria for that month. If the individual reapplies, new information that was not available at the time of the earlier determination could result in a different eligibility decision for some of the same retroactive months (See also 711 and 705-1 for limits on the date eligibility may begin.)