Do you have a household income that falls below the poverty line? Is your current income preventing you from affording dependable health coverage? If this explains your current situation, you should consider applying for Medicaid, a government healthcare program that assists low-income families and individuals in receiving the medical care they require.
Medicaid is an insurance program offered by the government that gives healthcare coverage to families and individuals who belong to low-income groups in society. Medicaid’s health coverage includes parents, children, pregnant women, people with disabilities, and senior citizens. Medicaid is a combined effort of which is funded by the states and the federal government. Each state runs its customized Medicaid program, which operates under the guidelines and policies of the federal government. Federal government guidelines cover a broad horizon of healthcare possibilities that allow each state to have remarkable flexibility in developing and executing its Medicaid plans. As a result, the terms and conditions, eligibility criteria, and coverage benefits offered by Medicaid vary significantly from state to state.
All states also offer Medicaid insurance programs for individuals who have limited assets or income and require home healthcare services, nursing home healthcare services, or long-term healthcare services. A few states also provide Medicaid spend-down programs – medically needy programs. These programs let you take out your medical expenses from your income, enabling you to qualify for Medicaid coverage.
Medicaid works on a significantly broader spectrum, and in 2018, it was stated that over the year, Medicaid delivered healthcare coverage to over 97 million low-income Americans. The Congressional Budget Office (CBO) reported that Medicaid covered 32 million children, 28 million low-income adults who belong to the working class, 9 million disabled people, and 6 million senior citizens in a given month.
In this article, we will highlight the details about how Medicaid works, what it covers, the eligibility criteria for Medicaid, and how you can apply for Medicaid coverage?
Table of Contents
- 1 What is Medicaid?
- 2 Who is eligible for Medicaid?
- 3 How to apply for Medicaid?
- 4 Is Medicaid free?
- 5 What does Medicaid cover?
- 6 What does Medicaid not cover?
- 7 How much does Medicaid cost?
- 8 How effective is Medicaid?
- 9 How does Medicaid work with Medicare?
- 10 Medicaid and Part D drug coverage
- 11 How the Affordable Care Act changed Medicaid?
- 12 Conclusion
What is Medicaid?
Medicaid is a phrase that refers to a government-run healthcare framework that helps low-income families and people in the United States with their medical and healthcare coverage. The national government and individual states both contribute to the program’s funding. Furthermore, Medicaid is administered at the state level, meaning the coverage range differs significantly from one state to the next.
Medicaid provides coverage to families and individuals who belong to low-income groups in society. Medicaid’s health coverage includes parents, children, pregnant women, people with disabilities, and senior citizens. Children enrollees cover up to two-fifth of people enlisted with Medicaid insurance and only consume up to one-fifth of Medicaid’s expenditures. On the other hand, one-fifth of Medicaid’s registered people are comprised of people with disabilities and senior citizens. However, people with disabilities and senior citizens often require more expensive healthcare services and treatments, so they consume a massive portion of Medicaid’s budget.
Who is eligible for Medicaid?
All the states have guaranteed financial support for a particular part of their Medicaid coverage from the federal government. This makes Medicaid an entitled program, and anyone who meets the eligibility criteria has a right to apply and get enrolled for Medicaid coverage. Each state must complete minimum coverage criteria in order to receive the federal government’s funding. The mandatory coverage population criteria for the states is;
- All children under 18 years who belong to families with income below 138% of the poverty line,
- Pregnant people with income below 138% of the poverty line,
- Caretakers or parents with extremely low income
- Senior citizens and people with disabilities surviving on cash assistance from the Supplemental Security Income program
Individuals’ Medicaid eligibility criteria regarding their financial situation can be best described in two categories; financial eligibility and non-financial eligibility.
A new methodology for assessing Medicaid eligibility, developed on Modified Adjusted Gross Income (MAGI), is introduced by The Affordable Care Act. The process of determining the financial eligibility for Medicaid, premium tax credit, CHIP, and cost-sharing reductions offered through the health insurance marketplace has become more effective due to MAGI. ACA has made the application process more accessible for people to apply in the appropriate program by using a single set of income counting rules and a single application across all the programs.
Most children, pregnant women, parents, and adults are eligible for Medicaid based on their MAGI. To check financial eligibility for Medicaid, the MAGI-based methodology takes taxable income and tax filing relationships into account. MAGI replaced the previous method of determining Medicaid eligibility, which was based on the methodologies of the AFDC program, which ended in 1996. The MAGI-based methodology does not permit income disregards that differ by state or eligibility group, nor does it let an asset or resource test.
Some people are exempt from the MAGI-based income counting rules, such as those who qualify due to blindness, disability, or age (65 and older). Medicaid eligibility for individuals 65 and older or with blindness or a disability is generally determined using the income methodologies of the Social Security Administration’s SSI program (some states, known as 209(b) states, use certain more restrictive eligibility criteria than SSI but essentially apply SSI methodologies). Eligibility for the Medicare Savings Programs, in which Medicaid pays Medicare premiums, deductibles, and/or coinsurance costs for beneficiaries who are eligible for both programs (also known as dual eligibles), is determined using SSI methodologies.
Certain Medicaid eligibility groups do not require the Medicaid agency to determine income. Enrollment in another program, such as SSI or the breast and cervical cancer treatment and prevention program, may be required to obtain this coverage. Children subject to an adoption assistance agreement under title IV-E of the Social Security Act are automatically eligible. Young adults meeting the eligibility criteria for former foster care recipients are also eligible at any income level.
The individual must meet non-financial criteria as well in order to be eligible to apply for the Medicaid coverage program. Generally, the beneficiary must be a resident of the same state in which he is receiving Medicaid coverage. Secondly, the beneficiaries must be US citizens or qualified non-citizens such as lawful permanent residents. In addition to that, some eligibility groups are also age-limited or by parenting status or pregnancy.
Medicaid eligibility for aged, blind, and disabled
Medicaid has a particular field for aged, blind, and disabled people (ABD). ABD Medicaid offers healthcare facilities like physicians visits, medical equipment, and hospital care in case;
- You are more than 65 years old, blind, or have any disability
- And you also meet all the financial eligibility criteria required to enroll in the Medicaid coverage program.
Medicaid eligibility for Medicare beneficiaries
In various scenarios, Medicaid works together with Medicare to provide coverage for your healthcare expenses. Medicaid also compensates for some services that are not covered under the coverage range of Medicare, for example, certain dental services, transportation to doctor visits, and extra home care.
Medicaid’s eligibility criteria for Medicare beneficiaries is explained below.
- Long-term care in a nursing home: All states offer one Medicaid program for beneficiaries who need long-term medical care in nursing homes. Such a program is called Institutional Medicaid. You are eligible for institutional Medicaid coverage if you necessitate a nursing home level medical attention, fulfill the nursing home’s eligibility requirements, and have income under specific guidelines from the state.
- Long-term care in the home or community: All states offer at least one program under Home and Community-Based Services (HCBS) that provides healthcare services coverage for people who require long-term care in their homes or community. Medicaid will only provide coverage for home healthcare if you fall under the criteria of being homebound and requiring extra skilled care. You must also meet the state’s functional eligibility criteria and belong to the income group under specific guidelines from the state.
Effective Date of Coverage
Once you determine your eligibility, your Medicaid coverage is effective either on the first day of the month when the application is submitted or on the application submission date. Benefits may also be provided back-date for up to three months before the month of submitting the application if the individual was eligible during that time if he had applied. Medicaid coverage usually ends at the end of the month in which a person no longer fulfills the eligibility requirements.
How to apply for Medicaid?
After understanding the eligibility criteria in detail, the best way to figure out your eligibility for Medicaid is to submit a Medicaid application. You can apply for Medicaid using the following two methods.
- Through your local Medicaid office
- Through federal healthcare insurance marketplace
You have to contact your local Medicaid office or federal health insurance marketplace to apply for Medicaid. Your local Medicaid office might have a different name, such as the Department of Insurance, the Department of Social Services, the Department of Health, Medicaid, or any other name. The primary guideline to apply for Medicaid is given below.
- Contact your local office to ask about the procedure of submitting the application for Medicaid. Some states may require you to apply in person only. In contrast, others may accept the applications through telephone, by mail, online, or by applying at community organizations and local health centers.
- You should have a detailed list of documents required for completing the Medicaid application. You may need the following documents in order to process the application.
- Birth certificate
- Proof of US citizenship (for example, driver’s license, passport, employment authorization card, or green card)
- Proof of all earned and unearned types of income (retirement benefits, paychecks stubs, Supplemental Security Income)
- Proof of resources (property, life insurance policy, bank statements, etc.)
- Proof of residence (rent receipt, deed, or landlords statement)
- Medicare or any other insurance card (or the copy of the insurance policy)
- If you are pregnant or need emergency medical care, you can utilize Medicaid coverage irrespective of your citizenship status. All you need is a doctor’s certification that you are pregnant or need emergency medical assistance. But you must meet all other eligibility criteria.
- Ask to discuss with the supervisor if you face any issues while applying at a Medicaid office.
- You can appeal for a fair state hearing if you do not receive a timely decision or your Medicaid application is turned down. Your Medicaid office will guide you more about the appeal process for a fair hearing.
- You must keep on recertifying your proof of eligibility even after getting Medicaid coverage. In many states, rectifying is an annual process; therefore, you must ensure with your Medicaid office how and when you are required to rectify.
Is Medicaid free?
Thinking that Medicaid will always cover 100% of your medical services is just a misconception. The fact is, many people still pay copayments even after being covered by Medicaid. They may also be required to pay some other expenses as well. How much medical care will be free depends on your income level and the state you are living in because each state operates its own Medicaid program with its own terms and conditions. The best way to estimate the expected costs you will have to pay is to visit your state’s Medicaid office.
What does Medicaid cover?
Medicaid is not a healthcare service provider itself. It is basically an insurance coverage provider that offers coverage for healthcare expenses to low-income individuals, adults, children, people with disabilities, pregnant women, and senior citizens. To make the coverage process possible, each state’s Medicaid program pays the healthcare service providers, hospitals, physicians, nursing homes, and other healthcare providers organizations for the medical expenses incurred for the services they provide to needy patients. Each state develops and executes its own Medicaid program and defines the services’ nature, amount, scope, and duration. State rules are made under the federal guidelines.
Since each state has its own Medicaid program, it can cover some additional services as well. Prescription drugs are covered by all the states in their Medicaid. There are a few optional services that most of the states cover, which are;
- Dental care
- Vision services
- Hearing aids
- Private care services for weak senior citizens and people with disabilities.
Although states are not required to provide these services and are taken as optional services, they are essential in meeting the healthcare needs of old and disable people.
Medicaid covers a variety of healthcare services that vary from state to state, but there are some benefits that Medicaid programs offered by all states must cover. They are;
- Doctor visits
- Inpatient hospital care
- Certified Pediatric and Family Nurse Practitioner services
- Rural health clinic services
- Family planning services
- Counseling to help pregnant women quit smoking
- Lab work and x-ray services
- Emergency care
- Preventive-care services for children
- Several other services for children under 18 years of age (for low-income families)
- Selected preventive care, known as EPSDT: early and periodic screening, diagnostic, and treatment services
- Home health services
- Nurse midwife and freestanding birth center services
- Transportation to medical care
Sometimes, your primary care physician can prove to the state that the treatment you need is essential medically and get Medicaid to pay for it. This is known as “prior authorization,” and it’s a common standard operating procedure followed by a variety of health insurance organizations in order to minimize the unnecessary expenses on treatments that are not medically essential.
Under Medicaid, the dental advantage is offered to children and all the states and adults in some states. Twenty-seven states provide preventive dental care in their Medicaid program, whereas 26 states allow remedial dental care services, such as cavity fillings, says the government report of June 2015. Moreover, emergency dental care for adults with Medicaid is provided by 19 states only. Eye tests and glasses are also covered in most of the states.
What does Medicaid not cover?
After knowing what does Medicaid cover, it practically seems like Medicaid covers almost every possible healthcare service anyone might need, which is not necessarily true. Medicaid does not provide coverage for private nursing. It also does not cover healthcare services rendered by a family member. Some services which are considered non-essential are also not covered under the umbrella of Medicaid. For example, Medicaid does not pay for chiropractic services or cosmetic surgeries.
Products like adult diapers, bandages, or other disposables are also not covered by Medicaid. Medicaid also won’t cover the medical expenses generated outside the United States unless a foreign healthcare service provider is closer than a domestic one.
In addition to the services mentioned above, Medicaid also won’t pay for;
- Healthcare services offered by another government agency
- Complications during or after a cosmetic surgery
- Beautician services and personal care items
- Free health screenings and given-away equipment
- Medical equipment that is replaced via warranty
How much does Medicaid cost?
For some Medicaid participants, each state can determine its own expenditures, deductibles, and cash-based expenses. Higher-income Medicaid recipients, defined as those with earnings at or over 150 percent of the poverty line, may have to pay more for healthcare expenses.
States could apply a coinsurance fee of 20% of the cost of each medication as a method to encourage the use of less expensive medications. In the event that members of this group visit the emergency room in a non-emergency situation, they may be charged the maximum amount for the healthcare service utilized. In this case, the doctors at the medical clinic should determine whether the visit was an emergency or not.
Some higher-level workers may also be able to pay minimum monthly Medicaid costs.
Children in California, for example, with families earning 160 percent to 266 percent of the federal poverty level, pay a monthly premium of $13 per child. Working people with disabilities in California can make up to 250 percent of the federal poverty level while still receiving full-scope Medi-Cal by paying a low monthly premium based on countable pay.
How effective is Medicaid?
There is no doubt about the effectiveness of the Medicaid health coverage program. Medicaid provides health insurance to the most vulnerable. It has helped reduce the number of uninsured people from 45 million to 29 million since the significant coverage expansion by ACA in 2014. Without Medicaid, most of the millions of people that are covered by Medicaid would have no medical insurance as the only option left for them would be private medical insurance. Most of the Medicaid beneficiaries cannot afford private insurance because they belong to a low-income group, and their jobs do not provide medical coverage facilities for them and their family members.
Since its creation, Medicaid has been taking steps to play its part in reducing the number of uninsured people. One of the significant steps in the process was expanding Medicaid coverage to pregnant women and children in the 1980s and 1990s. Other than the expansions, Medicaid is also playing its part in effectively growing access to healthcare by supporting unstable families financially and enhancing their healthcare results. The ACA expansion, providing coverage to low-income people, is ample proof of Medicaid’s efforts, which allowed researchers to compare the outcomes of states who adopted the expansion with those who did not.
Medicaid’s expansion not only reduced the medical debt in the states which adopted it but also increased the frequency of checkups for common and chronic diseases, improving overall well-being. It also offered benefits for children in the longer run. Research revealed that children with Medicaid coverage show fewer absences from school, better results, and turn out to be better-earning adults, facing more occasional hospitalization and emergency room visits.
How does Medicaid work with Medicare?
All the states offer various Medicaid programs that differ in their services and coverage from state to state. Their eligibility criteria and terms and conditions vary from state to state. If you register with a Medicaid program, it will be helpful for you in paying the healthcare expenses and services that are not covered under Medicare. There are a few ways Medicaid can work with your Medicare insurance program.
- Medicaid can offer you secondary insurance for the services and facilities that are covered by both Medicare and Medicaid. This means that if you visit a healthcare provider who takes both insurance plans, your Medicare insurance will pay first, and Medicaid will always pay last.
- Medicaid provides you with premium assistance by getting you enrolled in the Medicare Savings Program (MSP).
- Medicaid can help you in getting prescription drugs at lower costs as Medicaid individuals are automatically registered in the Extra Help program.
- Medicaid can provide you better care coordination as some states may demand Medicaid beneficiaries to register in the private health plans, also called Medicaid Managed Care (MMC) plans.
Medicaid and Part D drug coverage
If you have Medicaid and Medicare enabled, Part D will typically cover your drugs. Many states allow Medicaid to cover some of the medicines which are not covered under Medicare coverage by the government. The drugs which are not covered by the Medicare coverage and are maybe covered by your state’s Medicaid coverage program include;
- Fertility drugs
- Medicines for anorexia, weight gain, and weight loss
- Hair growth medicines or drugs for cosmetic purposes
- Drugs for relief from cold symptoms such as flu, cough, etc.
- Prescription minerals and multivitamins (excluding prenatal fluoride preparations and vitamins)
- Non-prescription OTC drugs
How the Affordable Care Act changed Medicaid?
Because of the Affordable Care Act, Medicaid now performs an even more significant role in providing insurance to low-income people of the United States. The Affordable Care Act expands the eligibility criteria of Medicaid to 138% of the poverty line. This expansion allows more excellent coverage to more people and individuals belonging to the low-income groups. The reports from April 2020 state that along with the District of Columbia, 35 states of the United States have executed the Medicaid expansion. This expansion proves to be a massive step for low-income and poor adults. By the end of 2029, it is expected that Medicaid will enroll 14 million more adults and low-income individuals to provide them access to affordable and better healthcare services.
This expansion appears to be a sound financial opportunity for most of the states. The federal government bore all the expansion costs for the first three years and now funds 90% of the extension cost on a constant basis. This expansion helped the Federal government to reduce the numbers of uninsured people significantly. Reduction in the uninsured people will help the states to save a greater quantity of money.
This article provides detailed insight into how Medicaid works and what is the eligibility criteria for applying for Medicaid coverage. Understand your eligibility carefully and apply for Medicaid coverage by using the easy process mentioned above. Medicaid coverage will help you get affordable healthcare services and provide better access to improved healthcare facilities. So what are you waiting for? Check the eligibility and apply for your Medicaid coverage now!