Medicaid is a federally mandated, state-administered health care program for low-income U.S. residents. There are some similarities between Medicaid and Medicare, but the two programs serve distinctly different populations. And while Medicare is federally operated and funded, Medicaid is operated through the states and funded by both the states and the federal government. More than 67 million people were enrolled in Medicaid in March 2018, according to the Centers for Medicare and Medicaid Services.
The program covers basic health care costs, including doctor visits, hospital stays, and nursing home care. Certain services may sometimes incur a small fee, but the intent of Medicare is to provide basic coverage for low income Americans of all ages.
The following article highlights the basics of Medicaid, including eligibility, coverage, and how to apply for benefits.
The primary factor determining eligibility for Medicaid is income. You also must be either a U.S. citizen or lawful permanent resident (i.e., green card) to be eligible, although the immigration status requirement is waived for people with emergency medical conditions, including pregnant women in labor. Some states also offer non-emergency prenatal coverage for pregnant women regardless of immigration status. Also, you must be a resident of the state in which you're applying for Medicaid benefits.
Children of families whose income is above the threshold for Medicaid coverage may be eligible for health care benefits through the Children's Health Insurance Program (CHIP).
Financial Eligibility for Medicaid
For purposes of Medicaid eligibility, income is determined by calculating the modified adjusted gross income (MAGI) of an individual or household. MAGI is adjusted gross income plus any untaxed foreign income, Social Security benefits, or tax-exempt interest. Income-based eligibility is expressed as a percentage of the federal poverty level (FPL).
Each state has different criteria for Medicaid eligibility , often segmented into groups (such as children, pregnant women, and adults).
In Florida, for example, infants up to one year old are eligible if family income is below 206 percent of FPL; but adults are eligible if family income is closer to 100 percent of FPL (Florida uses dollar amounts based on household size instead of FPL). In states that have expanded eligibility in accordance with a provision of the Affordable Care Act, unlike Florida, individuals and families with a family income below 138 percent of FPL qualify for Medicaid.
Exemptions From Income-Based Eligibility Requirements
Some individuals are exempt from income-based eligibility requirements, including those who are blind, have certain disabilities, or are 65 or older. Eligibility for these individuals is determined by methodologies used for the federal supplemental security income (SSI) program. Also, SSI beneficiaries automatically become eligible for Medicaid coverage in most states.
Other people who may be eligible for Medicaid include those in the breast and cervical cancer treatment and prevention program, children covered by an adoption assistance agreement under title IV-E of the Social Security Act, and young adults who meet the eligibility requirements as former foster care recipients.
Medically Needy Programs
Most states participate in a medically needy program through Medicaid in order to help cover people with very high medical expenses but whose income is too high to otherwise qualify for coverage. These programs allow patients to "spend down" the amount of income above a given state's medically needy income standard, after which they may be covered by Medicaid.
Medicaid Benefits and Coverage
Since Medicaid is intended to cover basic health care needs, it has its limits. But while the list of covered benefits varies by state, federal law mandates a certain baseline of coverage, including inpatient and outpatient hospital services, rural health clinic services, laboratory services, transportation to medical care, and a few other key services.
Optional benefits -- those that may or may not be covered by your state's Medicaid program -- include prescription drugs, physical therapy, dental services, eyeglasses, prosthetics, and respiratory care, to name a few.
Medicaid Enrollment and Appeals
You may enroll in Medicaid (or CHIP) through the Health Insurance Marketplace or your state's Medicaid website. If you apply for coverage through the marketplace and the data shows that anyone in your family is eligible, your information will be forwarded to your state agency.
If your application is denied, you have the right to appeal the decision. The state Medicaid agency is required to give you written notice of the denial ("notice of action") explaining the reason for denial, the specific rule the denial is based on, and information about how to appeal. Deadlines for requesting an appeal vary by state, but are no more than 90 days from the date the denial notice is mailed. If you're already receiving benefits, you'll want to file your appeal within 10 days to avoid a disruption of coverage.
Confused About Medicaid Eligibility or Coverage? An Attorney Can Help
If you're eligible for Medicaid, you should be able to apply online or in person without too much trouble. But if your application was denied for some reason and you believe the denial was in error, you may need help appealing the decision. Whatever your needs, a local health care law attorney will be able to point you in the right direction.