If you belong to a low income family, chances are that you will be hard pressed for your medical expenses. Spending on health when you do not have enough to rely on, can be disturbingly hard. If you have no help at hand, you might as well be thrown into the dungeons of deep and dark financial situations.
When you have enough on your plate already, a visit to the hospital can be overwhelmingly problematic because it will mean extra expenditure and waste of time. If you want to save yourself from the sudden and unwanted medical bills and make life a little easy for yourself, then you need to enroll for Medicaid health coverage.
It will be confusing and complicated the first time, you may find the information a little overwhelming. You would want to have all the information, from definition of the program to eligibility criteria, laid out before you in a simple and easy-to-understand language.
Well, if that’s what you’re looking for, then you have landed at just the right place: this article articulates all the complexities related with the Medicaid program and the sought after eligibility criteria.
Table of Contents
- 1 Why Choose Healthcare Insurance in the U.S.?
- 2 What is Medicaid?
- 3 Who is Eligible for Medicaid?
- 4 Structure of Medicaid
- 5 How to Apply for Medicaid?
- 6 What Does Medicaid Cover?
- 7 Medicaid Through Private Managed Care Plans
- 8 Medicaid and Medical Practitioners
- 9 Conclusion
Why Choose Healthcare Insurance in the U.S.?
Why do we even have to choose healthcare insurance? That’s a valid question because governments all over the world provide either universal or partial free healthcare services. That’s not the case in the United States though.
In the U.S. when you get medical care, you have to pay for it. And healthcare expenses are skyhigh in the States. According to the U.S govt. Own website, if you stay in a hospital for merely three days, yourbills ca go as high as $30000.
Now that’s staggering!
So, this is where your Insurance comes in. They pay for your expenses instead of burdening you. Health insurance systems and governmental coverage work together to save the population from the unbelievably high bills and ease the situation.
With insurance in place, you pay a little to the Insurance company in the form of “premiums” and the company pays off the healthcare bills for you when the time comes.
What is Medicaid?
Most people in the States have healthcare insurance.Healthcare coverage/insurance system is quite complicated with several companies as well as federal and state governments chipping in to provide relief to the masses.
The largest state insurance program is Medicaid. Medicaid primarily serves the low income families in times of disease or distress. It is a joint venture of the federal and state governments that provides coverage to approximately 72.5 millions Americans.
The eligibility guidelines and income limits are set by the Federal government while the execution of the system is a state business. Federal government has also prohibited any increase in the premiums for medicaid considering the fact that it serves low income people who are hardly in position to paymore.
The main beneficiaries of medicaid include children, pregnant women, senior citizens,and disabled people as per federal criteria, but many states have expanded the criteria to include all people with low income.
Who is Eligible for Medicaid?
The federal government criteria stipulates that individuals with income below “poverty line” are eligible for healthcare coverage. The basic guidelines regarding eligibility are set by the federal government, but states have the authority to make changes keeping within the limits stipulated at the center.
The eligibility criteria differ widely in different states, but in all states, it revolves around your income level, the size of your household (like how many children and dependents you have), disability, and even family status.
You are eligible if you are:
- A U.S. citizen
- A U.S. national
- Resident of the State where you are applying for assistance
- Permanent residence of the U.S
- Your income is considered low as per Federal Government’s Poverty level
The main beneficiaries of medicaid are children; they account for half of the total beneficiaries. The next big category of beneficiaries belong to elderly and disabled people. Pregnant women, children, senior and disabled citizens are all eligible for this insurance program.
Plans to expand healthcare coverage under medicaid to low income individuals without kids is on board too, but it will take time.
In some states, all individuals (regardless of being men, women , children able or disabled) below a certain level of income (133% of the federal poverty level) are part of medicaid.
What is the Federal Poverty Level?
Federal Poverty Level (FPL) is a measure used to judge a person’s income and whether a person qualifies for certain grants and insurance programs.
The Department of Health and Human services updates the guidelines on a routine basis signifying income limits and financial assets that point to poverty level or otherwise.
Note: Main operations of medicaid are controlled and conducted at state level. You should expect variations in sops and rules from state to state.
Structure of Medicaid
If you are a low income individual and you want to apply for a medical insurance program for coverage, it is your right to know about everything about medicaid- the most extensive insurance network.
Medicaid is a shared structure where funding is half and half between federal and the state governments. It is administered by the state governments and they have the authority to manage the population that receive the aid, modes of services, services covered in the program, as well as methods of paying the physicians and hospitals.
Federal government stipulates the basic rules regarding services and eligibility criteria; states make their own rules regarding the execution of policies.
Oftentimes, states expand the base of the program for the welfare and betterment of their people.
How to Apply for Medicaid?
Have a medical condition that requires a hefty amount of money and there is no room for it in your monthly budget?
And that is why we are going to take you through the process of applying for medicaid so you have one less thing to worry about!
Here we go!
Medicaid is a joint program of the Federal and State governments, but it is administered through states, so each state has its own set of rules and regulations regarding eligibility and application.
In every state, there is a limit of financial assets that you can own to be part of the program. Exceed the limit and you lose the health care coverage under this program.
Some states have expanded the program to include more of their citizens while in others, the eligibility criteria is strict. The best way to know if you are eligible is to apply without further delay.
There are two ways to apply for this health insurance program.
1. Health Insurance Marketplace
You can conveniently fill the form for this program with the Health Insurance Marketplace. If you are eligible for the benefits of this program or anyone in your house does, your information will be given to the relevant state agency and you will be contacted for the enrollment process.
2. Your State Medicaid Agency
You can choose to go directly to your state Medicaid agency and bypass the Health Insurance Marketplace. Your information will be sorted out against the state criteria and you will be informed about eligibility or non-eligibility.
Note: you should apply for medicaid in your state even if you are not sure about your eligibility for the program. You can be eligible for other state aids that are totally unaware of.
What Does Medicaid Cover?
If your income falls below a certain level and you have difficulty meeting your own or other family members’ medical expenses, then Medicaid is definitely a life saver for you. The program covers all the health care services for individuals or families that are hard pressed for money.
Since states have their own laws in addition to the broader federal guidelines regarding medicaid coverage, you should check your state coverage for premium benefits. But it will benefit you to know your basic rights under the program which are listed below.
However, you are covered for these mandatory benefits as per Federal laws whether or not your state has expanded the bse of the program:
- patient and outpatient services
- InLaboratory services and X-Rays
- Physician services
- Home health services
The above mentioned services are mandatory services; all states have them in place under their individual medicaid programs.
There are some optional benefits offered under medicaid as well and those are:
- All prescription drugs
- Complete case management
- Occupational therapy
- Physical therapy
In some states the coverage even includes your eyeglasses, dental checkups. Medicaid benefits are lifelines of parents with special or differently-abled kids.
The above mentioned characteristics of the program show that its a comprehensive coverage system that really cushions the beneficiaries against soaring medical expenses especially during tough times of recessions, inflation and job cuts.
Medicaid Through Private Managed Care Plans
If you are a U.S. citizen, then you know the complexity of the insurance system in the States. Being a hardcore capitalist nation, even public services have an obvious hint of private corporations. You may not find this in other countries, but this is how things work in the United States.
The insurance landscape of the United States is quite complicated. Most insurance plans rolled out by the governments whether federal or state, are executed through a system of private insurance companies’ inclusion.
If you have enrolled in your state’s Medicaid, there are high chances that you are part of one or the other private managed care plan that has a contract with your state regarding the healthcare services due to you under medicaid.
The inclusion of private plans is so high now that some two third of the members are receiving services through these plans.
State’s fee-for-services plan serves the rest of the beneficiaries.
In the past, the managed care plans’ role was limited. Only children and pregnant women were served through these programs, but they are increasingly becoming more prominent within Medicaid. They provide swift and smooth delivery and save the governments’ funds from extra burden as well.
The managed plans have their own network of service providers and they serve those enrolled in medicaid with their own healthcare providers. They help take pressure off the government , but face considerable risk in the process.
Medicaid and Medical Practitioners
Medical practitioners are an important part of the health insurance network in the States. The insurance company or plan that you enroll for is administered through managed plans as described above in the article.
The managed plans or insurance companies have their own network of PCPs (Primary Care Providers). You are linked with a PCP as you buy insurance, you contact your PCP in all matters related to health. The PCPs are paid by the insurance companies.
Profit or let’s say financial gains are at the heart of commercial activities, and medical practices are no different. They studied hard and worked day in and day out for profit and their own financial well being.
As a medical practice, you have distinct advantages and disadvantages with the medicaid program.
Here goes the list up and down sides of medicaid as a medical practice
- With Medicaid patients, you will be able to build a solid base sooner and easier. You do not have to spend extra money on marketing which is absolutely necessary with non-medicaid patients.
- You will have an extraordinarily extensive patient base because a staggering number of people are enrolled into Medicaid.
- If you are seeing a lot of medicaid patients, you will have low reimbursements. The reasons are obvious. Those who opt for medicaid are low income people and they do not have financial space for extra treatments. They will more likely stick to the very basics of treatments- the ones that are inevitable. In fact, their priority will be to go for only those services that are covered by the insurance plan. So you, as a medical practice, have lower chances of making money out of these patients.
- Too many administrative complications come with medicaid patients. You will have to communicate with the government in order to start treatments. Reimbursements take too long and the administrative permissions are often delayed for treatments. Since every medicaid patient will take a lot of time for application processing, you will have less time to spare for expanding your practice too. Time loss and money loss are two things that come with your medicaid patients.
In the times of inflation and economic recession, more and more people are in need of insurance programs to make ends meet. It can become extensively hard for people to manage their lives with huge medical bills if they are not covered by programs like Medicaid. Medicaid is a health insurance program for low income individuals. It is financed by the federal and state governments and administered solely by the state governments. The policies regarding services and coverage differ state-wise but the basic guidelines are given by the federal government.