Medicaid Coverage

Everyone knows that health insurance is essential and costly. Unfortunately, not everyone is covered by health insurance. Many people are unemployed or employed by a company not required to provide health insurance. Individual policies are often cost prohibitive. To insure that our neediest citizens have adequate health insurance, certain Americans are covered under a government program known as Medicaid.

What is Medicaid?

Simply put, Medicaid coverage is medical insurance program designed for low-income individuals and families. It is jointly funded by the federal and state governments. This insurance was created to provide coverage for children, the elderly (age 65 and over), and individuals who are blind, and/or disabled, and by other individuals eligible to receive federally assisted income maintenance payments.

How can an individual obtain Medicaid coverage?

In order to qualify for Medicaid coverage, the participant must meet one of the following criteria:

  1. Must have been eligible for a Supplemental Security Income cash payment for at least one month.
  2. Be currently disabled, blind, or pregnant
  3. Meet all other eligibility requirements, including income, property ownership, and/or age requirements. (Individuals age 65 and over and individuals under 19 years of age may be covered. Individuals living in foster care may be covered up to age 21.)
  4. Require Medicaid coverage in order to work
  5. Have a gross earned income that is insufficient to replace SSI, Medicaid, and any publicly funded attendant care.
  6. Be a resident of a nursing home

What are the benefits of Medicaid?

Since Medicaid is run jointly by state and the federal government, states must meet certain criteria in order to receive their matching federal funds. The health care help available through Medicaid must include a variety of services. There are a number of basic services that must be offered to eligible members of the population. Some of these services include:

  1. Inpatient and outpatient hospital services
  2. Physician services
  3. Surgical and medical dental services
  4. Nursing facility services
  5. Home health care for certain persons
  6. Family planning services and supplies
  7. Nurse and/or midwife services
  8. Laboratory services
  9. X-rays
  10. Pediatric services
  11. Those services provided by a family nurse practitioner
  12. Rural health clinic services
  13. Other ambulatory services covered under a state plan

Some states also provide home-based or community-based care waiver services to certain eligible persons. Some of these services may include personal care services, respite care, adult day health services, and home health aides. Some individuals with breast or cervical cancer, and certain individuals with renal failure may be eligible for Medicaid coverage.

How much does it cost?

Medicaid is operated on what is known as a “vendor payment program”. That means that payments are made not to individuals, but instead are paid directly to participating health care providers. These health care providers are required to accept Medicaid reimbursements as payments in full. States are allowed to charge participants small deductibles and/or co-pays for certain services. States may not, however, charge co-payments for emergency care and family planning services. Additionally, women who are pregnant, children under the age of 18, hospital or nursing home patients who are expected to contribute most of their income to institutional care, and certain other individuals are also exempt from co-payments. Medicaid does not require the individual to pay any premiums. Providers may not charge Medicaid patients fees over and above the Medicaid reimbursement amount. Medicaid recipients may not be denied services by any participating provider because of the patient’s inability to pay.

States may set limits on the amount of income an individual may have in order to be eligible for Medicaid coverage. When an individual’s income or assets exceed the state’s permissible Medicaid amount, that individual may only be eligible for Medicaid coverage after spending down their income or assets to a poverty level by incurring medical expenses. These spend-down amounts can be very high, especially for nursing-home residents whose income far exceeds the Medicaid eligibility level but who face enormous monthly expenses for care.

For Americans without the benefit of health insurance, Medicaid coverage provides these individuals with a good measure of health care. Neither age nor income precludes this Medicaid coverage.