Repeal of Retroactive Medicaid Eligibility

By Miriam Harmatz and Andrea Faverio

Background on Retroactive Medicaid Eligibility (RME):

Under the federal Medicaid statute, states must provide up to three months of retroactive coverage to a successful Medicaid applicant if the individual was eligible for coverage when services were provided during those three months prior to application.1 This important consumer protection provision is referred to as “Retroactive Medicaid eligibility (RME).” Consistent with the Medicaid program’s objective to protect low-income persons who otherwise cannot afford needed health-care, Congress passed RME to alleviate financial risk for vulnerable individuals and ensure that those without insurance had an easier path to medical care.

In 2018, Florida received approval from the federal government to “waive” the RME section of the Medicaid statute for non-pregnant adults over 21 and to limit coverage to one month. This was done pursuant to what is referred to as an “1115 waiver” request.2 Because these waivers are time limited, the 2019 Florida Legislature attempted to permanently eliminate RME through a statutory amendment.3 Although the amendment ultimately failed to pass during the 2019 legislative session, Florida continues to utilize the section 1115 waiver to cut funding and limit access to RME.4

Status and Impact: Example of how the RME elimination impacts people and providers:

This elimination of RME is hurting low-income frail and disabled Floridians and critical safety net health care providers. Consider this hypothetical example: On March 15th, “Joe” suffered a sudden heart attack and was rushed to the hospital by ambulance.  He was admitted, treated for four days, and sent home. Joe, who is 64 and uninsured, was already suffering from dementia. Since his heart attack, Joe’s dementia has gotten much worse, and his wife, Dora, cannot care for him at home. She calls a nearby nursing home and is told he needed to first apply for Medicaid and be found eligible before he could be admitted. She does not know how to use a computer and is unable to get through on the phone to a local agency for help in filing a Medicaid application. Meanwhile, Joe falls and is taken by ambulance to the hospital on April 15th. He is discharged after receiving a CAT scan and spending the night in the emergency room. Joe’s son, who is in the army and stationed overseas, finally files an application for Medicaid for Joe online on May 1st. Joe is found eligible on June 5th. Joe’s medical bills from May and June will be covered.  However, his hospital bills from March and April totaling $35,000 are not covered by Medicaid. Under RME, those bills would have been covered, and it is also more likely that he could have gone straight to a nursing home.

Next steps:

Until RME is restored, a number of low-income, uninsured Floridians like “Joe” and his family will suffer. It is important for the public and policy makers to hear directly from those who are impacted. If you, a friend, or a loved one have been hurt by the loss of RME, we want to hear from you and work with you on the Florida Health Justice STORIES initiative.

1.    42 U.S.C. § 1396a(a)(34).
2.    See, 42 U.S.C. § 1315(a).
3.    Florida Policy Institute. 2019. https://www.fpi.institute/senate-bill-192-would-put-vulnerable-floridians-in-jeopardy/.
4.    See Policy Transmittal Eliminating RME.