Medicaid

Medicaid varies by State

Each state may have its own name for the program. Examples include “Medi-Cal in California, “MassHealth” in Massachusetts, “Oregon Health Plan” in Oregon, and “TennCare” in Tennessee.

States may bundle together the administration of Medicaid with other separate programs such as the State Children’s Health Insurance Program (SCHIP), so the same organization that handles Medicaid in a state may also manage those additional programs. Separate programs may also exist in some localities that are funded by the states or their political subdivisions to provide health coverage for indigents and minors.

State participation in Medicaid is voluntary. In some states Medicaid is subcontracted to private health insurance companies, while other states pay providers (i.e., doctors, clinics and hospitals) directly.Some states have incorporated the use of private companies to administer portions of their Medicaid benefits.

These programs, typically referred to as Medicaid managed care, allow private insurance companies or health maintenance organizations to contract directly with a state Medicaid department at a fixed price per enrollee. The health plans then enroll eligible individuals into their programs and become responsible for assuring Medicaid benefits are delivered to eligible beneficiaries.

Also included in the Social Security program under Medicaid are dental services. These dental services are an optional service for adults above the age of 21; however, this service is a requirement for those eligible for Medicaid and below the age of 21. Minimum services include pain relief, restoration of teeth and maintenance for dental health.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a mandatory Medicaid program for children that aims to focus on prevention on early diagnosis and treatment of medical conditions. Oral Screenings are not required for EPSDT recipients and they do not suffice as a direct dental referral. If a condition requiring treatment is discovered during an oral screening, the state is responsible for taking care of this service, regardless if it is covered on that particular Medicaid plan.

Comparisons with Medicare

Medicare is an entitlement program funded entirely at the federal level. It is a social insurance focusing primarily on the older population. As stated in the CMS website, Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people of all ages with end stage renal disease. The Medicare Program provides a Medicare part A which covers hospital bills, Medicare Part B which covers medical insurance coverage, and Medicare Part D which covers prescription drugs.

Medicaid is a program that is not solely funded at the federal level. States provide up to half of the funding for the Medicaid program. In some states, counties also contribute funds. Unlike the Medicare entitlement program, Medicaid is a means-tested, needs-based social welfare or social protection program rather than a social insurance program. Eligibility is determined largely by income. The main criterion for Medicaid eligibility is limited income and financial resources, a criterion which plays no role in determining Medicare coverage. Medicaid covers a wider range of health care services than Medicare.

Some individuals are eligible for both Medicaid and Medicare (also known as Medicare dual eligibles). In 2001, about 6.5 million Americans were enrolled in both Medicare and Medicaid.

Eligibility

Medicaid is a joint federal-state program that provides health insurance coverage to certain categories of low-income individuals, including children, pregnant women, parents of eligible children, and people with disabilities. Medicaid was created to help low-income individuals who fall into one of these eligibility categories “pay for some or all of their medical bills.” Medicaid helps eligible individuals who have little or no medical insurance. While Congress and the Centers for Medicare and Medicaid Services (CMS) set out the main rules under which Medicaid operates, each state runs its own program. Under certain circumstances, any category of applicant may be denied coverage. As a result, the eligibility rules differ significantly from state to state, although all states must follow the same basic framework.

Poverty

Having a limited income is one of the primary requirements for Medicaid eligibility, but poverty alone does not qualify a person to receive Medicaid benefits unless they also fall into one of the defined eligibility categories. According to the CMS website, “Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the designated eligibility groups.

Categories

There are a number of Medicaid eligibility categories; within each category there are requirements other than income that must be met. These other requirements include, but are not limited to, age, pregnancy, disability, blindness, income and resources, and one’s status as a U.S. citizen or a lawfully admitted immigrant. Special rules exist for those living in a nursing home and disabled children living at home. A child may be covered under Medicaid if she or he is a U.S. citizen or a permanent resident. A child may be eligible for Medicaid regardless of the eligibility status of his or her parents or guardians. Thus, a child can be covered by Medicaid based on his or her individual status even if his or her parents are not eligible. Similarly, if a child lives with someone other than a parent, he or she may still be eligible based on his or her individual status.

HIV

Medicaid provides the largest portion of federal money spent on health care for people living with HIV/AIDS. Typically, low income people who are HIV positive must progress to AIDS before they can qualify under the “disabled” category (T-cell count drops below 200). More than half of people living with AIDS in the US are estimated to receive Medicaid payments.

Recent changes

Anyone seeking Medicaid must produce documents to prove that he or she is a United States citizen or resident alien.

Gifts of any kind made by the Medicaid applicant during the preceding five years are penalizable, dollar for dollar. All transfers made during the five year look-back period are totaled, and the applicant is penalized that amount after having already dropped below the Medicaid asset limit. This means that after dropping below the asset level ($2,000 limit in most states), the Medicaid applicant then has to re-pay all transfers during the preceding five years by private-paying for nursing home costs. Since the person has less than $2,000, there is no source of funds to pay the penalty. Elders who gift or transfer assets can be caught in the situation of having no money but still not being eligible for Medicaid.

Medicaid does not pay benefits to individuals directly; Medicaid sends benefit payments to health care providers. In some states Medicaid beneficiaries are required to pay a small fee (co-payment) for medical services.

How Do I Find Out About Medicaid in My State?

The National  Association of Medcaid Directors provides links to each state’s Medicaid program. There you will find who to contact, the programs and coverage in each state, and other state medical assistance programs.

Resources

Families USA provides a series of Web pages where you can a wide range of information on Medicaid. Individuals seeking to learn more about Medicaid will find the following topics addressed:

  • A description of Medicaid
  • Eligibility for Medicaid
  • Medicaid Benefits
  • Waivers
  • State Medicaid News and Updates