Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 27 - Department of Medical Services › Rule 016.27.21-007 - Pharmacy 2-21 and Medicaid State Plan Amendment (SPA) 2021-0009, based on Act 758

Current through Register Vol. 49, No. 6, June, 2024
Medical Services Policy Manual, Section A
A-210 Retroactive Eligibility
MS Manual 01/01/22
Refer to Health Care Procedures Manual for more
				information.
The State is required to provide retroactive eligibility for up
				to three (3) full months prior to the date of application to applicants
				who:
1. Received medical services in
			 the retroactive period; and
2. Were
			 eligible in the month the medical services were received.
Retroactive eligibility will be provided to applicants who were
				otherwise eligible in the month services were received regardless of whether
				they were ineligible at other times during the retroactive period. Retroactive
				eligibility is separate and apart from current eligibility, that is, applicants
				not eligible for the current period may be eligible for the retroactive period.
				Retroactive eligibility determinations are required for all categories, except
				ALF, ARChoices, Autism, DDS Waiver, QMB, and PACE.
Note:
Retroactive coverage for
				Newborns will not be given prior to the date of birth.
Note:
Beginning May 1, 2018, Adult
				Expansion Group recipients may be eligible for retroactive coverage thirty (30)
				days prior to the date of application. Retroactive coverage for the Adult
				Expansion Group is date specific.
Example:
James is approved for
				coverage in the Adult Expansion Group with an application date of September 15.
				He asks for retroactive coverage for a doctor bill with a service date of
				August 1. He is not eligible for retroactive coverage because his bill is for
				August 1 and retroactive coverage can only begin August 16.
Example:
James is approved for
				coverage in the Adult Expansion Group with an application date of December 31.
				He asks for retroactive coverage for a doctor bill with a service date of
				December 1. His regular coverage will begin December 1. As the thirtieth day is
				included in his regular coverage period, no coverage will be given for the
				previous month.
An application for retroactive eligibility may be made on
				behalf of deceased persons and eligibility will be provided if they were
				eligible when the services were received.
For cases in which an applicant has not resided in Arkansas for
				three (3) full months prior to the date of application, the retroactive period
				begins with the date the individual established residency in Arkansas. The
				"previous state" is responsible for the retroactive period prior to the time
				the applicant established residency in Arkansas. The eligibility worker is
				responsible for providing the "previous state" with information necessary to
				determine eligibility for its portion of the retroactive period.
Services for the retroactive period are subject to the same
				restrictions as services for the current period (that includes, without
				limitation: utilization review, benefit limitations, medical necessity). Prior
				authorization cannot be a condition of payment for services received during the
				retroactive period. However, such services are subject to the same Utilization
				Review standards as all other services financed under the State's Health Care
				(Medicaid) program. The State is not required nor obligated to pay for services
				which have been retroactively determined by Utilization Review to be
				unnecessary.
For cases in which an applicant has made partial or full
				payment for services received during the retroactive period, the state will
				make payment to the servicing provider if:
1. The services were necessary and the
			 applicant was eligible when the services were received; and
2. The provider is willing to refund the
			 payment to the applicant and bill the State for the services.
Medical Services Policy Manual, Section B