Medicaid 101

Health Insurance, Insurance, Medicaid

Medicaid Basics

Medicaid and CHIP (the Children’s Health Insurance Program) exist to ensure health coverage for low-income Americans. CHIP is designed to cover children of families who have incomes too high to qualify for Medicaid but too low to afford private coverage.

Many people think of Medicaid as being for younger Americans and Medicare for older Americans, but this is not strictly the case — for example, some nursing home and long-term care coverage is included under Medicaid requirements.

Each state determines its own Medicaid eligibility standards, in accordance with minimum federal guidelines. The federal government requires certain groups to be covered by Medicaid, including “categorically needy” individuals (i.e., recipients of SSI and families with dependent children receiving cash assistance). However, states retain broad discretion in deciding which groups are entitled to Medicaid coverage.

Medicaid Eligibility

Income eligibility is scheduled to change in 2014 as part of the Affordable Care Act (ACA). Previous income eligibility was 100% of the Federal Poverty Level (FPL), a baseline that is recalculated yearly. The ACA increased this value to 133% of the FPL. (For reference, in the 2013 FPL 100% of the FPL for an individual was $11,490 per year and 133% was $15,281.70. For a family of four, those numbers were $23,500 and $31,321.50 respectively.) Within certain conditions, if you do not qualify immediately for Medicaid, you may qualify after “spending down” — essentially, spending on medical expenses until you have reached the FPL limits that apply to your family.

Aside from income eligibility, there are also citizenship/residency/immigration requirements, and asset requirements. The latter vary, but in general, you are allowed to own a home and a vehicle, as well as a certain amount of cash and other assets. Check with your state Department of Social Services or similar organization for the requirements where you live.

Medicaid Benefits

Benefits of Medicaid vary by state, but must include mandatory items such as:

  • Hospital services, both inpatient and outpatient, as well as transportation to medical care
  • Physician, home health, and rural health clinic services
  • X-Ray/laboratory services
  • Pediatric/nurse practitioner services
  • Home health services and Licensed Medicaid Nursing Facility services
  • EPSDT services (Early and Periodic Screening, Diagnosis and Treatment) for children under the age of 21.

Optional state benefits include items such as:

  • Prescriptions drugs
  • Physical and occupational therapy services
  • Speech/hearing/language disorder services
  • Podiatry, chiropractic, and optometry services
  • Eyeglasses, dentures, and prosthetics

Medicaid Under Obamacare

The Affordable Care Act (Obamacare) is making changes to align Medicaid benchmark benefits with those in the new insurance exchanges. Items such as mental health coverage and prescription drugs currently considered as optional are expected to be mandatory, but the unusual issues with implementing the ACA suggests that the changes to the law may not be finished. In the end, what matters is what your state covers — but the most current information on mandatory vs. optional state benefits may be found on the Medicaid website under the Affordable Care Act tab.

With the current battles over the Affordable Care Act, and frequent changes at both state and federal levels, it’s wise to check with your state officials to determine whether or not you qualify, and if your benefits have changed in any way. The website contains the most updated federal information and provides links to state resources.

Finally, keep in mind that not all health care providers accept Medicaid because of relatively low reimbursement rates compared to most insurance providers. Check with your care providers to see how Medicaid coverage affects your individual situation.

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