Resource: Understanding the Stakes when States Revoke Retroactive Coverage from Medicaid Programs

This recent report by Leading Age illustrates the effects of states eliminating retroactive coverage in their Medicaid programs. While the report focuses on elder groups, many of the findings are relevant to the disability community. Notably, the report cites that losing retroactive coverage exposes individuals to: large debt; the loss of necessary care; and loss of Medicare affordability assistance. The report also mentions how eliminating retroactive coverage weakens provider networks. Readers will find more details on those issues on pages 10-12 of the report, and we have copied the report’s explanation of retroactive coverage below for the convenience of readers.

As written by Leading Age:

“Medicaid provides health insurance coverage for low-income and high-needs populations and is designed to meet the needs of this population. One particularly important element of this tailored design is to provide coverage for health care a person received prior to applying for or being enrolled in Medicaid. This policy, known as retroactive coverage, is a key financial protection for low-income, uninsured, and underinsured older adults, especially those who experience a health emergency, need long-term services and supports following an illness, or have other unexpected high-cost health care needs. It exists because Congress recognized that people cannot always apply for Medicaid as soon as they become eligible and often do not even know they might be eligible. Medicaid retroactive coverage saves many from devastating medical debt and opens the door to accessing necessary care. It also helps lessen the uncompensated care burden on providers, particularly nursing facilities and hospitals that serve a large percentage of low-income patients, making it possible for them to stay open and continue to serve the Medicaid population.

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Since Congress added the retroactive coverage benefit, at least 16 states have sought and been granted waivers to limit or eliminate it for some or all Medicaid populations. Five of these states currently have waivers in effect that take away retroactive coverage from some or all Medicaid-eligible seniors age 65 and older. Prior to the Affordable Care Act (ACA), CMS granted waivers of retroactive coverage in Delaware, Massachusetts, Maryland, Tennessee, and Utah. More recently, several states have asked to waive retroactive eligibility in conjunction with expanding Medicaid under the ACA to newly eligible, non-elderly adults with income below 138% FPL. In addition, in the past two years CMS has granted waivers to three states (Iowa, Arizona, and Florida) to eliminate retroactive coverage for nearly all of their Medicaid populations, including seniors age 65 and older, people with disabilities, and individuals needing long-term services and supports (LTSS) at home or in an institution such as a nursing facility.

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Six states (Arkansas, Indiana, Kentucky, New Hampshire, Massachusetts, Rhode Island) have targeted their waivers to eliminate retroactive coverage for adults newly eligible through expansion, and in some states, low-income parents as well. Oklahoma explicitly exempts people eligible through the aged/blind/disabled pathway (including people needing LTSS), and Utah only eliminates retroactive coverage for adults under age 65 eligible for its Primary Care Network demonstration. Maryland’s waiver is the most narrow, only waiving retroactive coverage for certain children eligible through a targeted coverage pathway. In addition, two states (New Mexico and Maine) recently withdrew or suspended their approved waivers of retroactive coverage. Finally, the waivers in Arkansas, Kentucky, and New Hampshire have been vacated by a federal court and are therefore not currently in effect. For the most part, these states limit retroactive coverage to the month of application. For example, if an individual applied for coverage on February 5th, retroactive coverage would be limited to services received on or after February 1st. An individual who applied on March 30th could be eligible for retroactive coverage beginning March 1st. A few states however, eliminate retroactive coverage altogether and only provide prospective coverage, meaning coverage does not begin before the date of application.”