Retroactive Coverage (210-RICR-40-05-3)

Medicaid coverage may start retroactively for up to three (3) months prior to the month of application for IHCC groups, unless explicitly excluded. To qualify, a person must have met the criteria for Medicaid eligibility during the retroactive period. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility. The provisions in this section do not apply to the MAGI-eligible individuals and families in the Medicaid Affordable Care Coverage (MACC) groups identified in the Medicaid Code of Administrative Rules, Affordable Care Coverage Groups, except when a person who is ineligible for coverage in one of these groups applies for MN IHCC in accordance with the provisions in Part 2 of this Subchapter.

A.Medicaid beneficiaries in the IHCC groups may request retroactive eligibility for up to three months prior to the month of application.

1.Eligibility criteria – To obtain retroactive coverage, applicants must meet all eligibility criteria related to the applicable IHCC group during the retroactive period. Retroactive coverage is also available to IV-E and non IV-E foster children and adoption subsidy family-related coverage groups.

a.The applicant must meet Medicaid eligibility requirements for each month in which an unpaid medical bill was incurred. Thus, retroactive eligibility may be determined for one, two, or three months of the retroactive period.

b.Only the income and resources available to the applicant in the retroactive period are used to determine eligibility. No deeming is required.

c.The following chart details beneficiaries’ eligible retroactive benefits:

d.At the time of application for Medicaid, if the applicant in one of these categories indicates that an unpaid health medical bill was incurred in the three-month period preceding the application, eligibility for retroactive coverage must be determined.

2.Limits – Current eligibility for Medicaid does NOT affect retroactive eligibility. A person denied Medicaid in the month of application may be eligible for retroactive coverage.

a.An applicant need not be alive when an application for retroactive coverage is made. A family member or authorized representative may sign and submit an application on the deceased person’s behalf.

b.Retroactive eligibility is not available to persons who were not residents of Rhode Island in the retroactive period at the time the service was provided. Retroactive coverage applies only to unpaid medical bills for services provided within the scope of the Medicaid program. The bills must have been incurred during the three month retroactive period.

c.Note: All services provided in the retroactive period and the costs incurred are subject to the same Title XIX utilization review standards as all other medical services of the Medicaid Program.