109.11 Application for Retroactive Medical Assistance, QDWI, SLMB, or SLMB135 (AAM)

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Advise individuals applying for financial or medical assistance that they are entitled to apply for retroactive medical assistance and/or SLMB, QDWI, or SLMB135 * for a 3 month period prior to the application date. Retroactive eligibility may be established for 1, 2, or all 3 periods directly preceding the date of application. Application for retroactive assistance can be requested and provided without qualifying for or requesting ongoing assistance.

*

The individual applies for retroactive assistance coverage on Form 779, Application for Retroactive Medical Assistance. The request must be made no later than a 9 month period from the first date of the retroactive period for which coverage is requested.

Example

If the date of application was May 12, then the retroactive months and the deadlines for requesting retroactive medical assistance coverage would be as follows:

Exceptions:

• Determine retroactive coverage for QDWI, SLMB, SLMB135, or * 1619 certified individuals and recipients of Refugee Medical Assistance in whole months from the first of the application month.

• Determine eligibility for retroactive months one month at a time. For each retroactive month, determine whether the individual would have been eligible for assistance if an application had been filed for that month.

• QDWI or SLMB135 * recipients cannot be eligible for Medicaid benefits and QDWI or SLMB135 * coverage in the same month.

• An authorized representative may apply for retroactive assistance on behalf of a deceased individual. Determine eligibility only for the retroactive period prior to and including the month of death.

• When the individual has not been a New Hampshire resident for the entire retroactive period, determine eligibility only for months in which New Hampshire residency is verified.

If the individual is eligible for a retroactive month, explain the retroactive billing and payment process.