Determining Medicaid Eligibility

When President Lyndon B. Johnson signed Medicare into law with the Social Security Act in 1965, he created another publicly funded medical program that fewer people are likely aware of. That program is referred to as Medicaid and is designed to provide needs based medical coverage to low income families, children, senior citizens, and others. The most basic principles behind Medicaid eligibility are a low income and a lack of resources to obtain medical care.

The Medicaid program is jointly administered by state and federal government institutions, with both sides sharing the burden of funding the program. Each state is responsible for the general operation of their Medicaid program, while the federal government plays the role of watchdog. The Centers for Medicare and Medicaid Services is responsible for ensuring that state governments are appropriately managing their Medicaid programs. Among the responsibilities of the CMS in the process include ensuring quality service is provided, funding is distributed appropriately, and that eligibility requirements are being followed.

Medicaid eligibility can be difficult to describe with one blanket statement because the rules for eligibility can differ from state to state. While the program is a joint effort between state and federal governments, the federal government establishes the guidelines which state governments must abide by in the operation of their programs. However, the guidelines set forth at the federal level are often basic Medicaid eligibility guidelines, allowing for states to determine further eligibility rules. Generally speaking the following individuals are eligible for Medicaid in most states:

  • Low asset children
  • Parents of low asset children
  • Pregnant women
  • People with disabilities
  • Senior citizens in need of nursing home care

These eligibility requirements are not all inclusive though and there are often further guidelines within each group of eligible individuals which help determine specific Medicaid eligibility. Other Medicaid eligibility requirements can include age, specific disability, financial resources, blindness, and legal status as a U.S. citizen or lawfully admitted aliens.

Poverty is a general starting point for determining Medicaid eligibility regardless of the state in which an individual resides. Many individuals with a low income and a lack of ability to pay for medical expenses are eligible for Medicaid, however just because someone is poor does not mean they automatically qualify for Medicaid. Individuals who live in poverty must fall into one of the categories listed above; meaning individuals or married couples without children are often determined to be ineligible for Medicaid.

One of the most controversial Medicaid eligibility requirements revolves around individuals living with HIV/AIDS. Medications and treatment for HIV/AIDS is very expensive, making it all but impossible for low income individuals suffering from the disease to seek treatment. Under Medicaid eligibility guidelines, an individual with HIV is not eligible for Medicaid assistance until they have progressed to having AIDS. This is defined by Medicaid as the individual having a T-cell count of 200 or worse, meaning they are officially considered disabled. However, many treatment programs and medical journals recommend treatment for individuals living with HIV/AIDS begin with a T-cell count of 350 or more depending upon the individual.

Finally, although Medicare and Medicaid are different programs, it is possible for an individual to be eligible for both forms of health care assistance. Medicare is available to all U.S. citizens and certain legal immigrants over the age of 65. Individuals with certain disabilities (such as ALS or End Stage Renal Disease) are also eligible regardless of age. Medicaid on the other hand is available to U.S. citizens and legal immigrants of any age and is determined, as mentioned earlier, based upon financial need.

Senior citizens who have very low incomes and are in need of expensive medical attention are eligible for both Medicare and Medicaid. Nursing home expenses are often the reason a senior citizen takes advantage of both assistance programs. Medicare’s coverage is limited when it comes to nursing home expenses, so those with little financial assets often turn to Medicaid’s help in covering the expense of a nursing home stay.

At the beginning of the 21st century there were nearly 6.5 million Americans who were eligible for both Medicare and Medicaid. With the largest segment of the American population, Baby Boomers, nearing their golden years between 2020 and 2040; Medicaid costs related to nursing homes is expected to sky rocket and stretch state budgets in the process.