If you’re poor, uninsured and fall seriously ill, in moststates if you qualify for Medicaid — but weren’t enrolled at thetime — the program will pay your medical bills going back threemonths. It protects hospitals, too, from having to absorb thecosts of caring for these patients.

But a growing number of states are rescinding this benefit knownas “retroactive eligibility.” On Nov. 1, Iowa joined three states that haveeliminated retroactive coverage for some groups of Medicaidpatients since the Affordable Care Act passed. Each state had to secure approval by the federal government.

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Retroactive eligibility has been a feature of Medicaid fordecades, reflecting the program’s emphasis on providing a safetynet for poor, disabled and other vulnerable people. In contrastto private insurance, determining Medicaid eligibility can becomplex and the application process daunting, advocates say. Apatient’s medical condition also may keep families from applyingpromptly for coverage.

All four states — Arkansas, Indiana and New Hampshire, in addition to Iowa — haveexpanded Medicaid under the health law, which allowed states toinclude adults with incomes up to 138 percent of the federalpoverty level, or about $16,000 for one person. So, in theory, mostadults are required to have insurance under the ACA. In practice,each state still has a significant numberof uninsured, ranging from 5 to 8 percent of thepopulation.

The retroactive coverage “can compensate for the sorts oferrors and lapses that can so easily occur on the part of both theapplicant and the government bureaucracy” that delay applications,said Gordon Bonnyman, staff attorney at the Tennessee JusticeCenter, a public interest law firm that represents low-income anduninsured residents.

State and federal officials say eliminating the retroactivecoverage helps encourage people to sign up for and maintain coverage whenthey’re healthy rather than waiting until they’re sick toenroll. It also fits into federal officials’ efforts tomake Medicaid, the federal-state program that provides health carefor low-income adults and children, more like private insurance.

But consumer advocates and health care providers say the shiftwill saddle patients with hefty medical bills and leave hospitalsto absorb more uncompensated care when patients can’tpay. Some worry this could be the start of a trend.

In Iowa, the change applies to just about anyone coming into Medicaid —except for pregnant women and children under age 1. The change willaffect up to 40,000 residents annually and save the programmore than $36 million a year.

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“We’re making it a lot more likely that Medicaid-eligiblemembers are going to incur significant medical debt,” said MaryNelle Trefz, health policy associate at the Child & FamilyPolicy Center in Des Moines, whose organization opposed thechange.

When someone has a traumatic health event, the initial focus isto get them stabilized, not figure out how to pay for it, saidMaryBeth Musumeci, associate director of the Program on Medicaidand the Uninsured at the Kaiser Family Foundation. (Kaiser HealthNews is an editorially independent program of the foundation.)

Patients may neglect to apply immediately for Medicaid,leaving them financially responsible for days ormonths of care they received before they got in theirapplication, even though they may have been eligible for Medicaidall along.

That’s not the only issue, advocates say. Unlike the commercialinsurance market where re-enrollment through someone’s employer isroutine, Medicaid requires that beneficiaries’ eligibility bereassesed every year.

“People fall through the cracks,” said Andrea Callow, associatedirector of Medicaid initiatives at Families USA, a consumeradvocacy group.

In addition, complications can arise for people who might needMedicaid coverage for long-term care services. “The criteria arecomplicated. For a layperson to find those criteria and figure outif they’re eligible” is challenging and they may need extratime, said Musumeci. Once patients have secured coverage, theymay already have accrued hefty expenses.

Maybe so, but some people argue that a 90-day retroactiveeligibility guarantee is counterproductive.

“We’re trying to get people to behave more responsibly, not lessresponsibly,” said Gail Wilensky, an economist who oversaw theMedicaid and Medicare programs in the early 1990s under PresidentGeorge H.W. Bush. “That is not the signal you’re sending” withthree months of retroactive eligibility. A 30-day time frame ismore reasonable, Wilensky said.

In contrast to Iowa, the waivers in Arkansas, Indiana and NewHamsphire generally apply only to adults who gained coverage underthe law’s Medicaid expansion. (Indiana’s waiver also applies toother groups.)

Kentucky has a request pending that, like Iowa, would eliminateretroactive Medicaid eligibility except for pregnant women andchildren under 1, according to KFF.

Under federal law, officials can waive some Medicaid coveragerules to give states flexibility to experiment with differentapproaches to providing services. And retroactive eligibilitywaivers in Medicaid are hardly new. A few states like Tennesseehave had them in place for years. Tennessee officialseliminated retroactive eligibility for all Medicaid beneficiariesin 1994 when the state significantly expanded coverage underTennCare, as Medicaid is known there. At the time, the state evenallowed uninsured people to buy into the program who wouldn’totherwise qualify based on income, said Bonnyman.

“There was no reason for anybody to be uninsured exceptundocumented immigrants,” said Bonnyman. “It didn’t seem to havethe potential for harm.”

But state officials revamped that program after seriousfinancial problems. Eligibility for TennCare has becomemore restrictive again.

Other states that waived retroactive coverage for at least someMedicaid groups include Delaware, Maryland, Massachusetts and Utah,according to the Kaiser Family Foundation.

Bonnyman said his group frequently works with Medicaidbeneficiaries who have medical bills they can’t afford thataccumulated during the months before they applied for Medicaid.

“If you’re a moderate- to low-income working family, one or twodays in the hospital is enough to ruin you financially,” hesaid.

Kaiser Health News, a nonprofit health newsroom whosestories appear in news outlets nationwide, is an editoriallyindependent part of the Kaiser Family Foundation. Please visitkhn.org/columnists tosend comments or ideas for future topics for the Insuring YourHealth column.