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Section 1115 waivers of retroactive Medicaid eligibility: lack of evidence raises flags and warrants caution
Section 1115 waivers of retroactive Medicaid eligibility: lack of evidence raises flags and warrants caution
- Collection:
- Health Policy and Services Research
- Author(s):
- Courtot, Brigette, author
Blavin, Fredric, author
Allen, Eva H., author
Arnos, Diane, author - Contributor(s):
- Commonwealth Fund, issuing body.
Urban Institute, issuing body. - Publication:
- Washington, DC : Urban Institute, July 12, 2021
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Eligibility Determination -- statistics & numerical data
Medicaid -- organization & administration
United States - Genre(s):
- Technical Report
- Abstract:
- Medicaid’s retroactive eligibility provision covers health care services received up to 90 days before the date a beneficiary applied for Medicaid coverage, provided the beneficiary would have been eligible for the program when the services were received. These protections underscore Medicaid’s function as a health care safety net program providing assistance when it is needed most. Congress envisioned retroactive eligibility as protecting people unaware of their Medicaid eligibility or unable to apply in a timely way because of the sudden onset of disease or injury. Since retroactive eligibility became part of federal Medicaid law in 1972, this mechanism has served many purposes; it has covered medical bills when an uninsured person experiences a major health event or accident, facilitated long-term institutional placements for people being discharged from the hospital who have not yet applied for Medicaid, and covered hospital charges for Medicaid-eligible newborns before their enrollment has been processed. Retroactive eligibility helps people avoid medical debt, which can negatively affect the physical and mental health—as well as the financial well-being—of low- and moderate-income people (Hamel et al. 2016). Retroactive eligibility plays an important role in hospitals and long-term care institutions, too, allowing providers to begin care as soon as needed, regardless of a patient’s date of application. Section 1115 of the Social Security Act authorizes the US Department of Health and Human Services to waive certain parts of Medicaid law and allows states to undertake demonstration projects promoting Medicaid objectives. Beginning in the 1990s, the department authorized Medicaid Section 1115 demonstrations waiving retroactive eligibility for certain populations, typically as part of experiments to expand eligibility and exclude traditional enrollee groups (MACPAC 2019). The nature of these experiments changed with the Trump administration; between 2017 and 2020, the executive branch approved six retroactive eligibility waivers that were not part of eligibility expansions and that applied broadly to Medicaid populations, including seniors and people with disabilities.4 In more recent Section 1115 waiver applications, state officials have asserted that waiving retroactive eligibility will familiarize beneficiaries with commercial insurance (that provides prospective coverage only), incentivize them to obtain and maintain health coverage even when healthy, and encourage them to apply for coverage as soon as they believe they meet eligibility criteria (MACPAC 2019). Despite retroactive eligibility’s long-standing role in Medicaid, little is known about how its absence affects beneficiaries and providers. Using qualitative and quantitative approaches, this study examines the effects of retroactive eligibility waivers to fill this research gap.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Extent:
- 1 online resource (1 PDF file (15 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 9918315984206676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918315984206676