109.09 Application for Retroactive Medical Assistance SR 13-30, 07/13 (FAM-A)

Advise individuals applying for financial or medical assistance, including Children’s Medicaid (CM) and Family Planning medical assistance, that they are entitled to apply for retroactive medical assistance for a 3-month period directly preceding the application date.

The individual applies for retroactive medical assistance:

• using DFA Form 779, Application for Retroactive Medical Assistance; or

• if applying for CM or MCPW, DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), can be used; or

• if applying for Family Planning medical assistance, DFA Form 800FP, Application for Family Planning Medical Assistance, can be used.

The request must be made no later than 9 months from the first date of the retroactive period for which coverage is requested.

Example:

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

Exception: SLMB, SLMB135, recipients of Refugee Medical Assistance, In and Out MA, and 1619 Individuals require full month retroactive periods, starting from the first of the month of application.

Determine eligibility for retroactive periods one month at a time. For each retroactive period, determine if all the following criteria apply:

• the individual received medical services which would have been covered by medical assistance; and

• the individual would have been eligible for medical assistance in the period the service was provided, if an application had been filed.

An authorized representative may apply for retroactive medical 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 period, explain the retroactive billing and payment process.