How Far Back Can State Medicaid Agencies Go in Requesting Eligibility and Coverage Information?

Eligibility Team
Researcher & Writer
February 09, 2016

There are two ways to answer this question. The first is in regards to current eligibility, and the second is in regards to former eligibility. When determining current eligibility, state Medicaid will look at your current and/or previous years’ income and household.

If you are currently receiving income, you will need to provide pay stubs or other documentation for weeks, possibly months’ worth of payments to establish a clear pattern. For things like custody, alimony, and child support, you may have to provide copies of custody paperwork, settlement papers, and divorce agreements. Anytime there are changes in your income or household size, you will need to report those to your local Medicaid office.

If you are self-employed, you will need to provide your Schedule C tax forms from the previous tax year. Since self-employed individuals often have inconsistent income, the Medicaid agency will look at the previous year as a benchmark of what you are likely to be making in the current year.

If you have documentation showing your income is less than it was in the previous year, you need to provide that when you apply. Additionally, if you are paying estimated taxes, you can provide the documentation supporting the income you are reporting for estimated taxes.

To address the second way of looking at this question, States are required to have laws in place that mandate health insurers to acknowledge and honor claims submitted by Medicaid within three years of service. That means a medical bill can be submitted and covered up to three years after the medical service. This means you may have coverage for medical bills you otherwise thought you would be responsible for.

This requirement was put in place by the Deficit Reduction Act of 2005 (DRA). The DRA was signed into law by President George W. Bush. This Act was highly criticized at the time because its intended purpose was to reduce federal spending on entitlement programs like Medicaid.

However, some of the positive benefits of this Act included the extension of time that eligibility and coverage can be addressed, which was discussed in this article. It also broadened eligibility for Medicaid in various areas by expanding funding for groups including physically challenged low-income children and victims of Hurricane Katrina. 

The regulations controlling Medicaid have changed and evolved many times over the last few decades. The direction of those changes has been determined by the controlling government party. However, once regulations are put into place, they are followed by all states and county offices, so you can be sure this rule regarding look backs applies to you regardless of where you live.

Eligibility Team
Written by
Eligibility Team
We are a team of experts dedicated to finding the right government programs for you. Our mission is simple: help people quickly and easily understand which programs they might be eligible for—all in one place. Our team is dedicated to researching and providing you with the most relevant information. We compile only the most trusted information from government sources into one place so you can find the facts you need and skip what you don’t.
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