It can be an extremely stressful situation if you, or a loved one, have unexpectedly incurred significant medical expenses.
Not only do you have to take care of the health issue, but you also have to worry about the financial burden of your illness or injury.
One possible avenue of help available to you could be retroactive Medicaid, even if you’re not currently enrolled.
Below, we’ll discuss what is retroactive Medicaid, what are the requirements, how to apply for it, and a lot more.
What is retroactive Medicaid?
Retroactive Medicaid can cover your qualified medical expenses for a period of time before you apply for Medicaid, as long as you were eligible for benefits at the time when you received care.
For example, let’s say you had to move into a nursing home on January 1st, 2021 due to unforeseen circumstances.
And even though you were eligible for Medicaid, you hadn’t yet applied and enrolled.
In this case, you’d have until April 2021 (up to 3 months in the vast majority of the states) to apply for retroactive Medicaid. In other words, even though you hadn’t applied in January, you can still have Medicaid cover your nursing home expenses.
How are the dates of retroactive benefits determined?
The way it is interpreted can be a bit confusing because the 3-month retroactive period begins on the first day of the month when you submit your application.
So, if you apply on April 15th, then the retroactive period begins on April 1st. And since the coverage period can go back a maximum of 3 months, you could get reimbursed for any expenses going back to January 1st.
Of course, this is assuming you were eligible for Medicaid during all of those three months (explained below).
Why is retroactive Medicaid important?
Retroactive Medicaid is important to support those low-income seniors and families who unexpectedly get hit with a significant medical bill.
For many seniors, the need for a hospital or nursing home stay can arise suddenly. It could be due to a serious injury that results from a fall, one that might require a lengthy rehab period for an older adult.
In such cases, you won’t have the time to get approved for Medicaid before you need medical care. And nursing homes can get expensive very quickly if you don’t have insurance.
But retroactive Medicaid provides you with a 3-month window to get enrolled into Medicaid so that your unexpected hospital stay doesn’t cause any additional financial burden on you or your family.
What is retroactive Medicaid eligibility?
There are two factors when it comes to eligibility for retroactive Medicaid.
The first is that you must meet the general eligibility requirements for Medicaid.
But for retroactive benefits, you have to meet those eligibility requirements for the whole period during which you want your medical expenses covered.
So, going back to our previous example, let’s say you were admitted to a nursing home in January, and you enroll in Medicaid by April.
You must have remained eligible for Medicaid during all three months of January, February, and March if you want reimbursements for that entire period.
It is also a possibility that you were Medicaid eligible for only two of those months, and then you’d have your expenses covered only for that period.
What are the eligibility requirements for Medicaid?
To be eligible for Medicaid, you must also meet the following eligibility criteria.
- You must be a U.S. national (citizen, permanent resident, or legal alien)
- You must have proof of residence in the state where you’re applying for Medicaid
- You must have a medical/insurance need
- You must fall within the low-income category (more details below).
In addition, you must also be one of the following:
- Pregnant
- Diagnosed with an ongoing disability
- Be responsible for a child 18 years of age or younger
- Legally blind
- 65 years of age or older
What is considered low-income for Medicaid eligibility?
To qualify for Medicaid, you need to be considered low-income, and here are the typical guidelines.
Income limits
- Single individual – Must be less than $2,382 / month
- Married couple – Must be less than $4,764 / month
Asset limits
- Single individual – $2,000.00
- Married couple – $4,000.00
But these are general guidelines and they can vary from state to state. To check your eligibility based on a variety of factors, visit benefits.gov.
What if my income and assets exceed the limits?
You’re not automatically disqualified from Medicaid if your income and assets exceed your state’s low-income eligibility requirements.
There are some assets, like your home where you live, your car, and more, that are exempt from being counted towards your assets limits.
And if you earn too much income for your state’s Medicaid, there are ways you can spend down your income to qualify for Medicaid.
And this might work retroactively as well. If you had qualified expenses (usually medical and wellness-related expenses) during those months, then you might still be able to qualify, even if your income exceeded the required limits.
Here’s a great explanation about Medicaid spend-down from the NY State Education Department.
You can contact your state Medicaid with questions about income/asset limits, exempt assets, and how to spend down excess income and assets to qualify for Medicaid if you need.
How do I request retroactive Medicaid?
In many cases, it’s a matter of simply checking a box in the Medicaid application form. If approved, then you’d be eligible for Medicaid reimbursements for the preceding three months, as we explained above.
In some cases you might be asked to fill out a separate form, depending on your state of residence.
But either way, the specific part of the form asking for retroactive Medicaid is quite straightforward.
What is usually more complicated is gathering all the documents that prove your eligibility during those preceding months.
You’ll need documents to prove that you fall within the category of low-income and that you have incurred qualified medical expenses.
How far back will Medicaid pay a claim?
As we’ve discussed above, in most states including NY, you can be eligible for up to three months of retroactive Medicaid benefits.
So, even though you have three months to enroll, you should get started with the application process as soon as possible.
If you or a family member have incurred unexpected medical expenses, look through the eligibility requirements above. If you qualify, then get started with the application process today.
What will Medicaid cover retroactively?
The services covered under retroactive Medicaid are the same ones covered under Medicaid. In other words, for any medical expense that would normally fall under Medicaid, you can also get reimbursed retroactively.
As long as Medicaid determines the services to be medically necessary, you can get reimbursed for the following services.
Home and community-based services
Medicaid covers home and community-based services where you receive care at home instead of a long-term care facility like a nursing home.
For example, in New York, if you have a disability you can hire a care provider of your choice to help you with daily living activities like grooming, bathing, personal hygiene, cleaning, and more.
And Medicaid would compensate your care provider through the Consumer Directed Personal Assistance Program (CDPAP) program.
The biggest advantage is that you get to live in the comfort and privacy of your home and get care from someone you like and trust. Instead of having to receive care at a nursing home.
In the case of retroactive Medicaid, you can start with your home-based care when you need it, and your care provider would get compensated for up to three months of work when you get approved.
Doctor appointments
You can get reimbursed for doctor’s appointments, but be sure to visit doctors in your area who accept Medicaid.
Here’s more information on how to find a doctor in your area who accepts Medicaid.
Durable medical equipment (DME)
Medicaid will pay for any durable medical equipment (DME) as long as it meets the following criteria.
- Equipment is medically necessary – The equipment must serve a medical purpose. In other words, it can’t be just for convenience or added comfort.
- It is cost-effective – Has to be the most basic version of that equipment. So, if you need a wheelchair, Medicaid will only cover the cheapest wheelchair that meets your medical needs sufficiently.
- Meets the definition of DME – Typically means that the equipment can be used repeatedly, like a wheelchair.
Hospice care
Many state Medicaid programs include hospice benefits, which can include various services for the terminally ill.
These services can include the following, and various others:
- Nursing
- Medical social services
- Doctor’s services
- Counseling for the patient and family members
In-patient/outpatient
In-patient means any medical service that requires you to stay in the hospital or emergency room (ER).
Outpatient services are ones where you receive treatment without being admitted to a hospital.
Lab/x-rays
Laboratory work, like blood tests, stool tests, etc. is covered by Medicaid. Or if you need x-ray or imaging services, you can also get reimbursed through retroactive Medicaid.
Non-emergency medical transportation
Non-emergency medical transport (NEMT) covers transportation services that aren’t emergencies.
Here are a few examples.
- Regular primary care visits
- Recurring treatments visits
- Physical therapy
- Mental health appointments
Nursing home care
We covered home and community-based care earlier in this section. But sometimes, that’s not an adequate solution, and you need to be treated at a nursing home.
Fortunately, Medicaid covers nursing home stays for eligible individuals. For retroactive Medicaid, be sure to go to a nursing home that accepts Medicaid.
Prescription drugs
If you are prescribed any medications by your doctor, you would be able to get reimbursed if/when you are approved for retroactive Medicaid.
One-time vs ongoing retroactive medical expenses
One thing to keep in mind when discussing retroactive Medicaid is the type of your medical expense.
If you had to go to the hospital all of a sudden due to an acute injury, but you left a couple of days later, that’s a one-time expense.
And as long as you were eligible at the time of care, you still have three months to get enrolled and have your bills covered by Medicaid.
But if you need ongoing care, such as at a nursing home, or at home through home-based care like CDPAP, then you’d want to have your ongoing expenses covered by Medicaid.
How payments/reimbursements work for retroactive Medicaid
To receive reimbursements, your provider (doctor, nursing home, hospitals, etc.) must accept Medicaid. So, be sure to research your provider if you plan on applying for retroactive benefits.
Assuming you’re eligible and you get your retroactive benefits approved, here’s how it would work.
Step 1 – You get approved for retroactive Medicaid and you receive your approval document.
Step 2 – You submit that approval document to your provider to whom you owe medical bills. You can attach the approval to the Medicaid benefits claim when you submit it.
You should also receive a Medicaid card in the meantime that you need to include with your claim. Note that if you haven’t received your card for some reason, your 3-month time limit will be adjusted accordingly.
Step 3 – Your provider gets paid through Medicaid insurance. Usually, there’s also a time limit within which providers need to ask for a reimbursement. So, be sure to submit all your documents as quickly as possible to avoid any delays.
What if I already paid my bills?
In some cases, you might be able to get reimbursed for bills you’ve already paid, as long as it falls within the retroactive period, and you were eligible when you received treatment.
You would have to show your provider that you’re approved for retroactive Medicaid, and then ask them to refund your payments. Your provider would then take your information and get reimbursed through Medicaid for their services.
But since this might not always work, it is a safer bet to do the following.
- When in need of sudden care, go to a nursing home or hospital that accepts Medicaid
- Find out if you’re eligible for Medicaid
- If eligible, immediately apply for retroactive Medicaid
- Inform your provider that you’re waiting for retroactive Medicaid
- Wait till you receive approval to take care of payments/reimbursements
Retroactive Medicaid forms
The specific forms you need for retroactive Medicaid would depend on what state you’re living in. For answers specific to your state of residence, contact your state Medicaid.
But here are some of the forms that might help give you a better idea.
Medicaid application form
The first thing you’ll need to do is fill out a Medicaid application form. In many states, that’s all you’ll need to request retroactive Medicaid.
You’ll just need to check a box stating you want coverage for previous medical expenses, provide any related information, and send in relevant documents for evidence.
Here’s the Medicaid application form for NY with detailed instructions.
Here’s information on how to apply for Medicaid in each state.
Retroactive Medicaid coverage form
Some states and territories, like Washington DC, have separate forms to apply for retroactive Medicaid, in addition to the regular Medicaid forms.
Here are the forms for Michigan and South Carolina retroactive Medicaid requests.
Contact your state Medicaid to find out if your state has a separate retroactive coverage form.
Key Takeaways
Life happens, and unfortunately, sometimes you can get hit with large unexpected medical bills.
And while it is never a pleasant experience, retroactive Medicaid provides you with a window of opportunity to save yourself, or your family, a potentially significant financial burden.
And this could also be the perfect opportunity for you to enroll in Medicaid so that you don’t face a similar situation in the future.
Review the requirements listed above, and if you are retroactively eligible for Medicaid, then don’t delay any longer – get started with your Medicaid application today.