Medicaid is a federally mandated, state-administered health care program for low-income U.S. residents. Medicaid is a public health insurance for low-income Americans and lawful residents. Medicaid helps ensure low-income adults and children can access long-term care and healthcare services, which leads to better health outcomes for more people. Individual states and the federal government jointly administer Medicaid through cost-sharing.
The following article highlights the basics of Medicaid, including eligibility, coverage, and how to apply for benefits.
The U.S. Department of Health and Human Services (HHS) jointly administers this medical assistance program with individual states and through the Centers for Medicare and Medicaid Services (CMS).
As of December 2022, the total number of Medicaid enrollees exceeds 90 million. The states receive federal funding to administer Medicaid, and they can tailor state Medicaid programs to achieve their long-term healthcare goals. Since states administer Medicaid, each state can set its eligibility requirements.
States must follow CMS regulations in tailoring their programs. States can apply for CMS waivers to try out new programs.
President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law in 2010. The intent of the ACA includes expanding health care coverage for low-income adults. The ACA does this through subsidizing health insurance premiums. Another way is through the Medicaid Expansion.
Before the ACA, some low-income adults could not qualify for Medicaid because their incomes were too high. They earned too much money to qualify for medical assistance but not enough to afford insurance premiums. In states with expanded Medicaid, low-income adults can qualify if their incomes are 133% of the federal poverty level.
The primary factor determining Medicaid eligibility is income level. The second eligibility factor is citizenship. Only U.S. citizens or lawful permanent residents can enroll in Medicaid. Medicaid waives this requirement 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.
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 Medicaid eligibility income purposes, states use a household's modified adjusted gross income (MAGI). MAGI is the adjusted gross income plus any of the following:
- Untaxed foreign income
- Social Security benefits
- Tax-exempt interest
Income-based eligibility is a percentage of the federal poverty level (FPL).
State Criteria for Medicaid Eligibility
Each state has different criteria for Medicaid eligibility, often segmented into groups such as children, pregnant women, and adults. State eligibility criteria include being a resident of the state.
For example, in Florida, infants up to one year old are eligible in Florida if their family's income is below 206% of FPL. Eligibility for adults is limited to those with a family income closer to 100% of FPL. Those with a family income below 138 percent of FPL in expanded Medicaid qualify for Medicaid.
Exemptions From Income-Based Eligibility Requirements
Some people are exempt from income-based eligibility requirements. These persons include:
- The blind
- People with certain disabilities
- Those 65 or older
The federal supplemental security income (SSI) eligibility criteria program applies to these persons.
Other populations eligible for exemption include the following:
- 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
- Former foster care recipients (young adults)
Medically Needy Programs
Most states participate in needy programs to cover people with very high medical expenses and incomes. Often, their income is too high to otherwise qualify for health coverage. These programs allow patients to spend down the income above the state's medically needy income standard. Once they meet the criteria, Medicaid will provide coverage.
Medicaid Benefits and Coverage
Although Medicaid covers essential health services, it has its limits, depending on where you live. Although the list of covered health benefits varies by state, federal law mandates a certain baseline of coverage, including the following:
- Preventative care like cancer screening
- Inpatient and outpatient hospital services
- Community-based services, such as rural health clinic services
- Laboratory services
- Transportation to medical care
- Nursing facilities, including nursing home care
- Intermediate care facilities, including mental health facilities
Optional Health Benefits
Health benefits that your state's Medicaid program may or may not offer include the following:
- Prescription drugs
- Physical therapy
- Dental care
- Respiratory care
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, the marketplace will forward your information to your state agency.
If the agency denies your application, you can appeal the decision. The state Medicaid agency must give you written notice of the denial ("notice of action") explaining the following:
- Reason for denial
- The specific rule that supports the denial
- Information about how to appeal
Deadlines for requesting an appeal vary by state but are at most 90 days from the date the agency mails the denial. If you're already receiving benefits, you'll want to file your appeal within ten days to avoid a disruption of coverage.
Get Legal Help
You or your loved one can apply for Medicaid online or in person without too much trouble. If the agency denies your application and you believe the denial was in error, you may need help appealing the decision. A local government services attorney can help you with your application or appeal. Speak to an experienced local government services attorney today.
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