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Why would states deny retroactive eligibility for Medicaid?

May 13, 2020

Topics: Quote of the Day

By Paul Shafer Nicole Huberfeld Ezra Golberstein
Health Affairs Blog, May 8, 2020

The coronavirus pandemic has led to record numbers of American workers being laid off or seeing their hours and paychecks dwindle. The economy is on the brink of a deep recession, and waves of coronavirus infections may continue for the foreseeable future. Medicaid will be a crucial piece of the puzzle that helps to ensure access to health care while protecting people from further financial ruin. Yet, one of Medicaid’s key provisions has been weakened by recently approved section 1115 “demonstration projects”, commonly referred to as waivers, that eliminate or reduce retroactive coverage. These waivers will diminish coverage for thousands of people seeking testing and treatment for COVID-19 and other medical care.

Retroactive eligibility is a long-standing feature of Medicaid that covers health care expenses for three months prior to the application date, provided that the beneficiary would have been eligible during that period. Before the Affordable Care Act (ACA), a handful of states imposed narrow restrictions on retroactive eligibility, but these limitations were paired with expansions of eligibility and had exemptions for vulnerable groups. Recently, however, many states—including Arizona, Arkansas, Florida, Indiana, Iowa, Kentucky, and New Hampshire—have gained Department of Health and Human Services (HHS) approval for 1115 waivers that drastically limit or completely eliminate retroactive eligibility, though four have been stayed by courts or halted by states as part of litigation challenging the legality of those waivers that include work requirements (Arkansas, Kentucky, Indiana, and New Hampshire).

A core purpose of Medicaid is supporting people when they need help, which is why Medicaid has continual open enrollment and retroactive eligibility to cover the cost of care when those who are eligible aren’t already enrolled before a crisis. States should restore full retroactive eligibility immediately to protect thousands of newly-unemployed workers from even greater health and economic suffering.



By Don McCanne, M.D.

In the absence of a universal health care financing program it is inevitable that many will remain uninsured because they do not qualify for whatever programs are available, or they simply cannot afford them. Thus the Medicaid program was established to provide a safety net for the uninsured who need health care but are too poor to purchase it.

When a low-income uninsured individual does develop a disorder that requires health care there is an administrative delay between the onset of the disorder and the time that enrollment can be completed. Thus the program provides for retroactive eligibility to cover care that was provided before enrollment could be completed.

Some states, for reasons of their own, have decided to create barriers that would prevent otherwise qualified individuals from receiving health care benefits under the program. For instance, the income level to qualify may be set so low that most poor people will not be able to participate. Currently there is also a fad of establishing a work requirement to determine eligibility even when such a requirement cannot reasonably be met.

The subject of this particular Health Affairs article is the effort of some states to reduce or eliminate retroactive eligibility even if the individual racked up considerable expenses because of the severity or abruptness of the disorder before the Medicaid application could be processed.

But the purpose of the Medicaid program is to cover expenses for poor individuals who are uninsured, and the program recognizes that retroactive eligibility is sometimes essential to provide that coverage. So why do some states want to defeat the program by prohibiting retroactive eligibility, or by introducing other policies that prevent individuals from receiving the benefits for which the program was designed? It seems cruel, but how could cruelty be their policy goal? Or is it just an intense ideological opposition to having government play a role in addressing such societal needs even if cruelty happens to be an unintended consequence of such a policy?

Although there is a perpetual dispute over states’ rights, this is one instance where the federal government should prevail. Avoidable cruelty cannot be tolerated in a just society.

We could end much of this nonsense by establishing a single payer national health program – an improved version of Medicare that covers everyone while eliminating financial barriers to care. It seems futile to ask them to stop being cruel; let’s just take it out of their hands instead and enact and implement Medicare for All. I can’t imagine that they would respond with demonstrations using placards that say, “WE WANT MORE CRUELTY.” But then I confess that I really don’t understand what all is going on today.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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