How to Get Retroactive Medicaid Coverage

You never know when a health crisis will develop, and the sudden expense of needed medical care can leave you short on resources to pay. Retroactive Medicaid coverage helps millions of Americans with limited means pay for the healthcare they got on an emergency or hurry-up basis, without prior insurance, to help manage the cost of treatment for unforeseen injuries or illnesses. Backdating Medicaid benefits can also help healthcare providers cover their costs, which encourages hospitals and other care providers to accept people for treatment even when they arrive with no insurance and are unable to pay up front.

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The Basics of Medicaid

Medicaid is the joint federal-state health insurance program that provides basic medical coverage for millions of eligible Americans. Funded in part by the federal government, Medicaid is administered at the state level and offers low-income health insurance for people with limited means, citizens with dire medical needs and pregnant women who need prenatal care.

Medicaid coverage varies by state, but all Medicaid systems provide funding at fixed rates for basic treatment and preventive services, as well as some transportation and prescription drugs. Participants in the program often have a choice of healthcare providers, though they usually need a primary care doctor who can authorize diagnostic tests and specialist care. Most systems have strict eligibility standards for new applicants.

Are You Eligible for Medicaid?

Medicaid programs in every state impose limits on income and assets for applicants seeking health coverage. The exact figures vary with the local cost of living, but all Medicaid systems start from the federal benefit rate, which in 2020 stood at $783 a month for individual applicants and $1,175 a month for married couples. Many states allow people who earn more than these amounts to apply for Medicaid, though most systems gradually increase the share of cost beneficiaries are expected to cover on their own. People who earn 300% of the poverty limit are generally not eligible for Medicaid coverage, though exceptions are sometimes made in cases of medical necessity and permanent disability.

How to Use Medicaid

Once your application to take part in Medicaid is approved, the coverage works much like any other health insurance. Beneficiaries are issued a card to present at the point of payment for services, equipment or drugs, which is then scanned for the invoice. Many Medicaid beneficiaries have a share of cost or co-payment requirements as part of their plans. These costs must be fully paid before Medicaid can accept additional costs. If you have Medicare, those benefits take priority first, with Medicaid acting as a supplement.

Most states provide Medicaid coverage through private sector insurers. Third-party plans may be organized as HMOs or as PPOs, which also function like any other health plan. The major exceptions in how care is paid for are:

• All services and equipment are paid for at the same fixed rate.
• Medicaid participants cannot be billed for services by an authorized Medicaid provider.

Can Medicaid Be Backdated?

If you arrive at the hospital without insurance or large amounts of ready cash, you’re likely to worry about how to pay for the services you need. Retroactive Medicaid helps allay those fears by picking up the costs you would normally have covered if you had been approved for a Medicaid plan before your hospitalization.

It is also common for Medicaid benefits to cover residential care services, such as admissions to nursing homes and memory care facilities. Most of these facilities have care coordinators who can assist families with their applications for retroactive Medicaid. In most states, your application may be backdated by up to 3 months for services you would have been eligible to receive had you been enrolled in Medicaid at the time. Be aware that several states have restricted this window to just 30 days or 10 days.

What Services Will Medicaid Backdate?

Retroactive Medicaid pays for largely the same services Medicaid benefits usually cover. These include:

• Hospitalization, including outpatient services
• Medical office visits
• Necessary medical transportation, both emergency ambulance and non-emergency van rides
• Prescription drugs
• Durable and disposable medical supplies and equipment
• Diagnostic tests authorized by a doctor, such as X-rays, MRIs and blood tests
• Nursing home, memory care and hospice admissions
• Home health services
• Regular services provided by state home- and community-based service (HCBS) programs

While most states’ Medicaid can retroactively provide coverage for the same services normally paid for, there are exceptions to every rule. Always check with a Medicaid worker or healthcare benefits coordinator before assuming a service can be paid for after the fact.

Applying for Retroactive Medicaid Coverage

Most states make it relatively easy to apply for retroactive Medicaid. All of the usual application paperwork must be submitted, along with verification of income and assets to establish eligibility. There might also be a telephone interview with an intake worker before your claims are accepted, though this is not universal. Approval for Medicaid often takes a few weeks. If the services you’re asking to cover are already close to the 3-month deadline, they will still be included in your Medicaid claim in almost all cases, provided your application is received before the time limit passes.

You may apply for retroactive Medicaid online, by phone or in person at your local human services office. Use the same application form as for regular Medicaid, and let your healthcare provider know that you’ve begun the application process as early as possible. Medicaid vendors can be severely penalized for billing a Medicaid enrollee for covered services, and most will delay invoicing you until you can provide their billing departments with a Medicaid authorization number. If you are not approved for Medicaid coverage, be aware that you may still be billed for all services provided to you while you were uninsured.