How do you get your retroactive Medicaid Benefits?

You have won your SSI benefits. Now, how do you get your retroactive Medicaid benefits?

It is not easy and it does require that you mark your calendar and file Medicaid Appeals when deadline dates are not met by Social Services and your medical care providers, as well as your pharmacy. You are asking DSS to do their job and give you the benefits you should have gotten when you Applied for Medicaid… not an easy task in many locations!

  

If you attempted to apply for Medicaid at the Department of Social Services and the following happened:

• DSS (Department of Social Services) told you that you could not be eligible for Medicaid unless you had already won your Disability status with the SocialSecurity Administration;
• DSS denied your Medicaid based on a Denial by Social Security while you were in the SSA Appeal process;             
• DSS denied your Medicaid Application without making an independent determination of disability by MDU
• Someone at the DSS discouraged you from applying, such as telling you that it is a waste of time because you would not be eligible

YOU NEED TO FILE A MEDICAID APPEAL if you did not when you first Filed for SSI! You will be asked why you did not File a Medicaid Appeal within 30 days of the denying event, tell them you did not understand their system and relied upon their "greater knowledge".

On the Medicaid Appeal form you are asked when did the violation of your Rights occur (they ask you when did you get Notice from DSS of the Appeal Issue); they will say you should have Appealed within 30 days, however IF YOU RELIED UPON THE REQUIRED SUPERIOR KNOWLEDGE OF THE DEPARTMENT OF SOCIAL SERVICES PERSONNEL, you have the Right to Appeal based on not knowing your true Rights until you found out this information from this site. On the Hearing day, there may be a “pre-Hearing” discussion on the issue of “good cause” for filing the Medicaid Appeal after 30days. We have never lost a case when the Applicant was able to clearly state that they had relied upon the statements made by DSS employees and the DSS employees were wrong.

Once you have an effective date of Application established, either by Filing the Application or by the Hearing Officer determining what you Application date was, your Medicaid eligibility must be determined for a period of 90 days prior to that Application date.

ELIGIBILITY

You must meet income, resource, and disability restrictions. Any earnings in your household may count toward the monthly maximum allowed amounts. IF YOU APPLIED FOR SSI AND WERE FOUND ELIGIBLE FOR SSI, all of those dates of coverage must be accepted  by DSS as Medicaid eligible dates from the 90 days prior to the date of your Medicaid Application to the last date of SSI eligibility. Periods after SSI eligibility must have a new Medicaid Application and a new determination of resource and income eligibility. You may only be eligible for Medicaid under a Spend Down plan (similar to a “deductible amount” in regular insurances) after your DIB benefits begin. If you continue to receive as little as $1.00 per month of SSI, you will keep your Medicaid.

For example, if SSI approved you for benefits from Jan 1, 2007 through July 31, 2007, and you applied for Medicaid on April 1, 2007 (and got a denial), the full period from 1/1/07 through 7/31/07 will have Medicaid coverage. If you applied for Medicaid November 10, 2006, and got a Denial from DSS, now DSS must determine your eligibility for Medicaid by income and resources and disability from November 10, 2006 through December 31, 2006.

Remember that your MEDICAID APPLICATION DATE limits when your Medicaid coverage can begin. That is why we urge you to APPLY FOR MEDICAID, DO NOT DELAY.

RECOVERY OF MEDICAL FEES AND PRESCRIPTIONS PURCHASED

If you paid for medical or psychological care or prescriptions, you are eligible for receiving that amount, minus your Medicaid co-pay, back form the provider. You MUST have told the provider that you had “Medicaid pending” when you obtained services, except at the pharmacy.  I asked you to obtain a “master printout” from your pharmacy and told you to keep track of the amounts paid to the providers. This information will assist you when you are seeking your funds back.

If you have not kept track or obtained a master printout of prescriptions, do so before you present a Medicaid card to them.

When your Medicaid benefits will be for a period over 12 months prior to the card issue date, the Department of Social Services must provide you with a ”greater than 12 month” letter that your providers can use to file for the Medicaid Coverage prior to the exact date one year ago. You will give each provider a copy if that letter and a copy of the Medicaid card (or allow them to copy these two items) when you provide notice to the provider to refund your money paid. Also tell them that this Claim must be “hand processed”. You should do this in writing, keep a copy and mark the date on your calendar. Your letter should tell them that they have 30 day deadline for refunding your payments, minus your Medicaid co-pays. They will know how much your co-pay was to be for the service they provided. Mark your calendar for 30 days; also mark your calendar for 15 days and on the 15^th day call the person you directed your letter to and confirm that they have everything they need. If the provider tells you that the Claim was denied, tell them to file an Appeal but you have complied with your Regulatory requirements: provided your Medicaid card that covered the period of service, and a letter allowing the billing of services more than 12 months prior to the filing date.

The provider will then file a PAPER CLAIM to Medicaid, placing a qualifier 22 on the claim and attaching a copy of the greater than 12 month letter from DSS.