109.09 Application for Retroactive Medical Assistance (MAM)

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Advise individuals applying for medical assistance that they are entitled to apply for retroactive medical assistance and/or SLMB, QDWI, or SLMB135 for a 3-month period directly preceding 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 medical assistance using:

. DFA Form 779, Application for Retroactive Medical Assistance; 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:

Exceptions:

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

. Determine eligibility for retroactive months one month at a time. For each retroactive month, 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 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 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 month, explain the retroactive billing and payment process.