Medicaid agencies make annual checks to account balances to ensure a Medicaid recipient still meets the right requirements. Still, beyond that, it's up to you to notify your agency if something affects your eligibility.
Retroactive coverage for all other groups, including Nursing Home Medicaid, begins the first day of the month in which the application was received. Other states, like New York, Illinois, and California (Medi-Cal), have not eliminated or reduced Retroactive Medicaid for any eligibility group.
If investigated by MICs, generally, there is a 5-year, look-back period. ZPICS have no particular look-back period, but with a good attorney, reasonableness can be argued. How can you be audited once you are no longer liable to maintain the records? The CERT program is limited by the same fiscal year.
By setting up an irrevocable trust and transferring into it any assets in excess of the Medicaid financial limits, you can effectively shield those assets from the program's fines and other penalties. One issue here is that assets cannot be transferred back out of the trust, so you have lost control of them forever.
There are also two state exceptions when it comes to the Look-Back Period – California and New York. There is no Look-Back Period for HCBS Waivers in California, and it's 30 months (2.5 years) for Nursing Home Medicaid, although that will be phased out by July 2026, leaving California with no Look-Back Period.
Once assets are placed in an irrevocable trust, you no longer have control over them, and they won't be included in your Medicaid eligibility determination after five years. It's important to plan well in advance, as the 5-year look-back rule still applies.
The lookback period in 49 of the 50 states is five years and begins as of the date of the Medicaid application. However, in California, the lookback period is only 2.5 years (30 months). If Medicaid finds ineligible transactions, the applicant will be assessed a penalty.
Specific Service Types: Excessive billing for certain services, such as high-cost procedures or those frequently subject to fraud and scrutiny, are more likely to be audited. Also, regularly billing for procedures or treatments that are not commonly performed might also raise concerns for an audit.
Generally, the IRS can include returns filed within the last three years in an audit. If we identify a substantial error, we may add additional years. We usually don't go back more than the last six years. The IRS tries to audit tax returns as soon as possible after they are filed.
You can only request retroactive coverage up to 6 months in the past.
Once the plan year ends, any old medical bill with a date of service prior to the new coverage effective date won't be covered by your new insurance coverage. You'll need to file a claim with the previous health insurance policy.
Certain services are covered in every state, including:
Inpatient hospital services. Outpatient hospital services. Physician services. Skilled nursing facility services.
Does Medicaid Check Bank Accounts? This one has an easy answer – yes. You will need to provide a variety of documents to verify the information you provide on your Medicaid application, and that is sure to include checking and savings accounts.
In general, a single person must have no more than $2,000 in cash assets to qualify. If you're over 65, the requirements are more complex. Whatever your age, there are strict rules about asset transfers. Medicaid may take into consideration any gifts or transfers of cash you've made recently.
California eliminated their asset limit effective 1/1/24. While this means one's home is automatically safe from Medicaid while they are living, the home is not necessarily safe from Medicaid's Estate Recovery Program.
Although each state statute is slightly different, MFCU investigations always involve: billing fraud involving the Medicaid program; abuse and neglect of residents within facilities that receive Medicaid payments; and. misappropriation of patient funds by such health care facilities.
Failure to recertify the plan of care when appropriate. Noncompliance with frequency/duration rules indicated within Local Coverage Decision (LCD) Insufficient documentation. Post-denial modification to documentation.
In 2025, there are only two exceptions to the 60-month “look back”. California is one exception, and while the state has a much more lenient Look-Back Period of 30-months (2.5 years), it is currently being phased out altogether. By July of 2026, there will be no Look-Back Period.
The person you care for can transfer assets into an irrevocable trust to protect them from Medicaid spend-down or penalties, as long as they set up the trust more than five years prior to applying for Medicaid. Any assets in the trust must stay in the trust until after your loved one passes away.
If you inherit money and do not report it, you will be required to pay Medicaid back for the services and benefits that were provided during any period you would have otherwise been ineligible. When a Medicaid recipient receives an inheritance, it is counted as income in the month that it is received.
A transfer into an irrevocable trust can be considered a gift for Medicaid eligibility purposes. This gift status/condition works as a significant negative for people applying for Medicaid assistance. In particular, both “penalty period” and 60 months “look-back period” rules apply.
Essentially, the five-year lookback means that an individual applying for Medicaid must disclose any gifts/transfers made by the individual or the individual's spouse within the five years leading up to the Medicaid application. Any such gifts result in a penalty period.
5-year rule: If a beneficiary is subject to the 5-year rule, They must empty account by the end of the 5th year following the year of the account holders' death.