How To Qualify For Medicaid?

Medicaid is the federal-and-state-funded health insurance program for low-income, needy Americans and their families.

Medicaid is a joint federal and state program that, along with the Children’s Health Insurance Program (CHIP), gives health coverage to over 72.5 million Americans, including children, pregnant ladies, parents, seniors, and people with disabilities. Medicaid is the single biggest wellspring of health coverage in the United States. In the event that you need long term care and cannot afford to pay for either the veritable care you need or any type of insurance or annuity protection, you should apply for coverage under the Medicaid program.

To participate in Medicaid, federal law expects states to cover certain groups of people. Low-income families, qualified pregnant ladies and children, and people getting Supplemental Security Income (SSI) are instances of compulsory eligibility groups. This program gives managed care to individuals who are disabled or 65 years old or more and have pay and assets that fall beneath certain federal and state limits. States have extra alternatives for coverage and may decide to cover other groups, for example, people getting home and community-based services and kids in child care who are not otherwise qualified.

How does Medicaid work?

Medicaid was made in 1965 to cover medical care for Americans unfit to work. The program is voluntary. States do not need to participate, however they all do. Participating states should meet parameters set by the Center for Medicare and Medicaid Services to get federal subsidizing, however they likewise have a great deal of authority over qualification and covered medical services.

President Barack Obama’s medical care law moved to standardize Medicaid necessities, specifically so any American making up to 133% of the poverty line could qualify. Yet, that arrangement was tested and overturned by the Supreme Court. States could expand Medicaid, however, they didn’t have to. 35 states (in addition to Washington, D.C.) did; 15 did not. Furthermore, qualification across states varies since the Trump administration reported it would permit states to force work necessities for low-income  and poor Americans getting Medicaid. All in all, sorting out whether you fit the bill for Medicaid is much more testing than before.

What does Medicaid cover?

Medicaid does not technically cover everything, but it does cover a lot. The federal government necessitates that certain services be offered to all Medicaid beneficiaries. These compulsory services include the following:

  • Care provided by physicians, nurse midwives, and nurse practitioners
  • Care provided in community health centers and rural health clinics
  • Care provided in nursing facilities for people 21 years of age and older
  • Early and periodic screening, diagnostic, and treatment (EPSDT) services
  • Family planning services and supplies
  • Home health care for people eligible for nursing facility services
  • Laboratory and imaging services
  • Transportation for medical reasons

Nevertheless, each state has the option to expand on those services — and they do that often. These optional services may include but are not restricted to:

  • Case management
  • Dental care (including dentures)
  • Durable medical equipment
  • Hospice care
  • Mental health services
  • Prosthetic devices
  • Prescription medications
  • Rehabilitation services (including physical therapy and occupational therapy)
  • Telemedicine
  • Vision care (including eyeglasses)

How to qualify for Medicaid?

Almost every state has various Medicaid programs. However, as a good rule of thumb, if you earn below 100% or below 200% of the federal poverty level (FPL) and are pregnant, a senior citizen, disabled, a parent/caretaker or a child, there is likely a program for you. Moreover, if you earn below 133% of the FPL, there is most probably a program for you, based on whether your state expanded Medicaid under Obamacare. In 2019, the federal poverty level in Alaska ranged from $15,600 (for one person) to $54,310 (for eight people). The federal poverty level in Hawaii ranged from $14,380 (for one person) to $49,940 (for eight people).

Financial Eligibility

The Affordable Care Act set up another approach for deciding income eligibility for Medicaid, which depends on Modified Adjusted Gross Income (MAGI). MAGI is utilized to decide financial eligibility for Medicaid, CHIP, and premium tax credits and cost sharing reductions accessible through the health care coverage commercial center. By utilizing one bunch of income counting rules and a single application across programs, the Affordable Care Act made it simpler for individuals to apply and sign up for the proper program.

MAGI is the reason for deciding Medicaid income eligibility for most children, pregnant ladies, parents, and grown-ups. The MAGI-based methodology considers taxable income and tax filing connections to decide financial eligibility for Medicaid. MAGI substituted the previous process for ascertaining Medicaid qualification, which depended on the procedures of the Aid to Families with Dependent Children program that ended in 1996. The MAGI-based methodology does not take into account income disregards that differ by state or by qualification and does not consider a resource or asset test.

A few people are absolved from the MAGI-based income counting rules, including those whose qualification depends on blindness, disability, or age (65 and more). Medicaid qualification for people who are 65 years old or more, or who are blind or disabled is generally figured out using the income methodologies of the SSI program managed by the Social Security Administration (a few states, known as 209(b) states, utilize certain more prohibitive qualification standards than SSI, yet at the same time generally apply SSI methodologies). Qualification for the Medicare Savings Programs, through which Medicaid pays Medicare charges, deductibles, or potentially coinsurance costs for recipients qualified for the two programs (frequently alluded to as dual eligibles) is determined via SSI methodologies.

Certain Medicaid qualification groups do not need an assurance of pay by the Medicaid office. This coverage might be based on enrollment in another program, like SSI or the breast and cervical cancer treatment and prevention program. Kids for whom an adoption assistance agreement is basically under title IV-E of the Social Security Act are automatically qualified. Young adults who meet the necessities for qualification as a previous child care beneficiary are likewise qualified at any pay level.

Non-Financial Eligibility

To be qualified for Medicaid, individuals also need to meet specific non-financial eligibility criteria. Medicaid recipients generally must be residents of the state in which they are receiving Medicaid. They must be either citizens of the United States or certain eligible non-citizens, for instance, legal permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.

Asset Limits and Exemptions

Medicaid has strict asset limits of $2,000 per candidate and $4,000 for couples, albeit this might differ from state to state. Since Medicaid is rarely straightforward, there are additionally various exceptions. For instance, if your spouse needs nursing home care but you plan on staying at home, you might be qualified to keep a lot of assets, usually upwards of $100,000 in many states. You may likewise be qualified to gather at least $2,155 or up to $3,259 of your spouse’s pay as a minimum monthly maintenance needs allowance to assist you with taking care of your bills and everyday  costs.

The following items are considered countable assets:

  • Certain annuities
  • Cash and bank accounts
  • Investments
  • Life insurance policies with a cash value
  • Revocable trusts
  • Secondary homes or vehicles

Exempt assets include:

  • A primary vehicle
  • A primary home up to a fixed value
  • Household items
  • Personal property
  • Retirement accounts

The American Council on Aging gives a state-by-state eligibility guide. You can visit MedicaidPlanningAssistance.org to find the income limit for your state.

Effective Date of Coverage

When a person is thought to be qualified for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months before the month of application, if the individual would have been qualified within that period had he or she applied. Coverage typically stops at the end of the month in which a person no longer meets the requirements for qualification.

How to qualify for both Medicare and Medicaid?

Medicaid

You may be eligible for free or low-cost care through Medicaid depending on income and family size. In all states, Medicaid gives health coverage for certain low-income people, families and children, pregnant women, the elderly, and people with disabilities. While in some states the program covers all low-income adults below a particular income level.

  • Find out if your state is expanding Medicaid and understand what that means for you.
  • If your state is expanding Medicaid, go to the website hhs.gov and find out what you may qualify for depending on your income and family size.

Even if you were told you are not eligible for Medicaid in the past, you may qualify under the new guidelines. You can see if you are eligible for Medicaid 2 ways:

  • Visit your state’s Medicaid website. Use the drop-down menu at the top of the page to choose your state. You can apply instantly and find out if you qualify. If you are eligible, coverage can begin immediately.
  • Fill out an application in the Health Insurance Marketplace. When you complete the application, we will tell you which programs you and your family qualify for. If it looks like anyone is qualified for Medicaid and/or CHIP, we will let the state agency know so you can sign up.

Medicare

Typically, Medicare is available for individuals who are 65 years old or more, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). Medicare has two parts, Part A (Hospital Insurance) and Part B (Medicare Insurance). You are qualified for premium-free Part A if you are at the age of 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at the age of 65 without having to pay premiums if:

  • You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
  • You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
  • You or your spouse had Medicare-covered government employment.

To figure out if you are eligible and your expected premium, go to the Medicare.gov eligibility tool. If you (or your spouse) did not pay Medicare taxes while you worked, and you are 65 years old or more and a citizen or permanent resident of the United States, you may be able to purchase Part A. If you are under the age of 65, you can get Part A without having to pay premiums if:

  • You are a kidney dialysis or kidney transplant patient.
  • You have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months. (If you have Lou Gehrig’s disease, your Medicare benefits begin the first month you get disability benefits.)
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While most people do not have to pay a premium for Part A, everybody must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every 3 months.

Dual Eligibility

Who is eligible for both Medicare and Medicaid? A few Americans qualify for both Medicare and Medicaid, and when this occurs, it ordinarily implies that they do not have any out-of-pocket healthcare costs. Recipients with Medicare and Medicaid are known as dual eligibles – and represent about 20% of Medicare recipients (12.1 million individuals). Dual eligibles are categorized dependent on whether they get partial or full Medicaid benefits.

Full-benefit dual eligibles have comprehensive Medicaid coverage, while partial benefit dual eligibles get assistance with Medicare’s premiums and cost sharing through a Medicare Savings Program (MSP). (A few recipients have Medicare, Medicaid and an MSP.) The federal government manages Medicare qualification – which means that it is very similar in each state. Be that as it may, states set their own qualification rules for Medicaid and the MSPs (staying within federal rules) – and income limits for these programs differ broadly.

At the point when dual eligible recipients have healthcare costs, Medicare pays first and Medicaid pays last. Yet, this is not the case for things Medicare does not cover, as long term care. In case Medicaid is covering a recipient’s long term care, Medicare will in any case be the essential payer for any Medicare-covered services – like skilled nursing care or physical therapy. In spite of the fact that it is more uncommon, if a dual eligible individual has extra coverage, (for example, a Medigap plan) then, Medicare pays first, Medigap will pay second, and Medicaid is the last payer for their claims (for costs covered by each of the three)

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Recipients can see whether they are eligible for Medicaid by getting in touch with their Medicaid office. An Internet search for Medicaid offices in a recipient’s state ought to give the number to call – however recipients should ensure that they are reaching out to a government office prior to sharing any personal information.

The Centers for Medicare and Medicaid Services (CMS) additionally keeps a list of state organizations that manage Medicaid. Recipients can check whether they currently have Medicaid by reaching 1-800-MEDICARE and finding out if they get “Extra Help” with their prescription medication costs (recipients with Medicaid are automatically signed up for this program).

By and large, recipients earning under 135 percent of the federal poverty level are eligible for the MSP in the event that they additionally have restricted savings (albeit a few states do not expect recipients to have low assets). This is the same as $17,226 yearly for single recipients and $23,274 for married couples. Recipients qualify for full Medicaid benefits if their incomes and assets are even lower (however the specific sums differ from state to state).

Numerous seniors who live in nursing homes are dual eligible: they qualify for Medicare dependent on their age, and Medicaid due to their monetary conditions. It is likewise not unexpected for Medicare recipients who are under 65 and live on Social Security Disability Insurance (SSDI) to get Medicaid benefits.

In case you are dual eligible, you can join up with a dual eligible special needs plan (D-SNP) that covers both Medicare and Medicaid benefits. These plans may likewise pay for costs that Medicare and Medicaid do not cover individually, including over-the-counter items, hearing devices, and vision or dental care. Recipients who are dual eligible can switch between Original Medicare and Medicare Advantage or switch Part D plans at each quarter.

How to apply for Medicaid?

If you are qualified for Medicaid, you can apply all year round via your state’s Medicaid website or HealthCare.gov, the federal health insurance marketplace. If you enroll for Medicaid via Healthcare.gov and it looks like you are eligible, then the federal government will make it known to your state agency, which will get in touch with you about enrollment. States also typically let you print out paper applications you can mail, fax or return directly to your local government office.

To complete your Medicaid application, you will most probably need to give documentation that proves that you meet your state’s requirements. This documentation may include:

  • Birth certificate or driver’s license to serve as proof of age and citizenship
  • Copies of bank statements
  • Medical records to serve as proof of disability
  • Proof of address, which could include a lease, utility bill statements or a copy of your mortgage
  • Recent pay stubs or tax returns to serve as proof of income

States have 45 days to deal with your Medicaid application. They have 90 days in case qualification is linked to a disability (Disability can prompt a permanent drop in income). In the event that you do not qualify for Medicaid, you could possibly get sponsored health care coverage through Healthcare.gov. In any case, just certain life events permit you to apply for a marketplace health care plan outside of open enrollment, which happens from Nov. 1 to Dec. 15 every year.

What is the income level to qualify for Medicaid?

Income qualification is dictated by your modified adjusted gross income (MAGI), which is your taxable income, in addition to specific deductions. Those allowances incorporate non-available Social Security benefits, individual retirement contributions and tax exempt interest. For a lot of people, MAGI is indistinguishable or exceptionally close to your adjusted taxable income, which you can discover on your tax return. Specific income prerequisites in dollars ascend along with the size of your family.

HHS distributed the federal poverty rules for 2021 on January 13, 2021. For a single individual, the 2021 federal poverty level is $12,880 in the continental U.S. For each extra individual in the family, the federal poverty level increases by $4,540 (so for a family of three, for instance, the 2021 federal poverty level is $21,960). So in a state in the continental U.S. that has expanded Medicaid (which incorporates most, but not all states), a single adult is eligible for Medicaid in 2021 with a yearly income of $17,774. Medicaid eligibility is determined dependent on current monthly, so that adds up to a limit of $1,481 each month.

The 2021 federal poverty level for a single individual in Hawaii is $14,820, with an increase of $5,220 for each extra individual from the family. Furthermore, for a single individual living in Alaska, it is $16,090, with an increase of $5,680 for each extra individual in the family. Both Alaska and Hawaii have expanded Medicaid under the ACA, so Medicaid is accessible to adults younger than 65 if their family income does not surpass 138% of the federal poverty level. Premium subsidy eligibility in the two states begins at 139% of the poverty level, which is an alternate dollar amount in each state, since they have diverse federal poverty levels.

(Remember that the 2021 poverty level rules are utilized in 2021 for Medicaid and CHIP qualification, while the 2020 federal poverty rules are utilized to decide qualification for 2021 premium tax breaks and cost-sharing reductions. The 2021 poverty level rules will be utilized throughout the fall 2021 open enrollment period, to decide qualification for 2022 premium tax breaks and cost-sharing reductions.)

What to do if you do not qualify for Medicaid?

In the event that you do not qualify for Medicaid, you might conceivably get sponsored medical care through the Obamacare commercial centers during an uncommon enrollment or open enrollment period. Americans who make somewhere in the range of 100% and 400% of the FPL qualify for a premium tax credit that can fundamentally bring down the expense of an arrangement. Federal open enrollment for 2019 medical services plans finished on Dec. 15, 2018, however some state trades are open longer and Nevada sells health care coverage throughout the entire year. Healthcare.gov, the federal trade, ordinarily opens from November 1 to December 15 every year.

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If you cannot find affordable health care on your marketplace during open enrollment, you have a few other alternatives. These include:

  • Short-term health insurance: Originally made to avoid short-term health insurance gaps, these plans are inexpensive, but much less comprehensive than conventional coverage. They do not have to cover Obamacare’s ten essential benefits or pre-existing conditions. Following changes by the Trump government, short-term health plans can last from three months to potentially three years.
  • Limited benefit plans: These plans provide coverage for a very tiny portion of the costs linked with certain “medical events”, like a doctor’s visit or ambulance ride. Both the number of events and dollar amounts covered are capped.
  • Prescription discount cards: While these cards will not help you pay for inpatient or outpatient care, they do help you get medication at discounted rates.
  • Healthcare sharing ministries: This is a faith-based alternative to health insurance in which individuals and families pay a monthly “sharing amount” just like a health insurance premium and use those funds to provide coverage for ministry-approved medical costs.
  • COBRA: The Consolidated Omnibus Budget Reconciliation Act (COBRA) lets you keep your health insurance from a soon-to-be-ex-employer for up to 3 years, though you are required to pay the full expense of the policy.

Conclusion

Qualifying for Medicaid is anything but a simple cycle, and with state-by-state adjustments and changes, it is not getting any simpler to enroll. Make sure that you get all of the help you can from a financial consultant and a qualified elder care lawyer before you start this process to expand your odds of getting accepted. Additionally, be ready to prepare and radically lessen the size of your acceptable estate through a giving or donation program to meet the limits and requirements for your state.

Sandra Johnson

Sandra Johnson

Sandra Johnson was a few years out of school and took a job as a life insurance agent in California, selling coverage door-to-door for Prudential. The experience taught her about the technical components of insurance and its benefits for individuals and society, as well as the misunderstandings people often have about insurance. She has over ten years’ experience in the insurance industry, having worked as both a Broker and Underwriter, assisting clients across a broad range of industries. At Insurance Noon, Sarah diligently gathers all the required information and curates up pieces to provide meaningful insurance solutions. Her personal value proposition is to demonstrate a genuine interest in always adding value for clients.Her determined approach to guiding clients has turned her into a platinum adviser to multiple insurers.

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