Medicaid

What is Medicaid

Medicaid (created in 1965) is a healthcare public insurance program that provides health coverage to low-income households while also providing much-needed assistance for individuals (children, low-income adults, senior citizens, pregnant women, and people with disabilities) in need of long-term medical care.

Contrary to Medicare (a social insurance program) which typically caters to individuals aged 65 years or older, Medicaid caters to an assortment of healthcare-related expenses for people of all ages.

Medicaid funding

Medicare is funded by the federal government and the individual states.

Each state administers its own Medicaid program according to very broad federal guidelines hence a great deal of flexibility in designing and running this program. This has seen the program’s eligibility and benefits vary widely from one state to the other.

The Centers for Medicare and Medicaid Services (CMS) is responsible for the implementation of Medicaid.

Eligibility for Medicaid income

Medicaid is a joint federal and state health insurance program for mandatory eligibility groups.  E.g. Low-income families, qualified pregnant women and children, individuals receiving Supplemental Security Income (SSI), etc.

The individual States may come up with additional options for coverage that are inclusive of other groups e.g. individuals on home and community-based services, children in foster care(otherwise not eligible), etc.

Medicaid Sign Up

Individuals who are 18 or older can sign up for the program.

1.      Through the Health Insurance Marketplace

Create an account and Fill out your application via the Health Insurance Marketplace

• State agencies are informed of eligible households by information shared with them.
• Take the opportunity to shop around and find out if you qualify for any other suitable plan bases based on your income.

2. Through your state agency

The application process is made of three parts:

• This includes Filling and turning in your application.
• A financial appraisal of the application will be done to determine the applicant’s financial eligibility.
• Lastly, a personal care needs assessment will be done to determine functional eligibility.

Information you will need to provide includes:

• KYC documentation which includes; Your Social Security number and Proof of identification.
• Proof of having an income.
• Financial Statements e.g. property tax statements, bank statements, life insurance.
• Documents proving Immigration status.
• Proof of citizenship if not covered by Medicare or Supplemental Security Income (SSI).
• Manual materials are needed for the long-term care application process.

What Medicaid Covers

Mandatory benefits will include:

• Hospital expenses
• Nursing home stays
• Doctor visits
• Hospice care
• Pregnancy care
• Vaccination for children
• Tests and x-rays

Optional benefits:

• Prescription drugs,
• Case management,
• Physical therapy, and
• Occupational therapy.

The coverage offered by the program is so broad and comes in handy in covering many costs associated with long-term care.

As Prescription drugs are not covered by Medicaid, an eligible person can use the program to pay a premium for Medicare Part D (prescription drug plan).

Please keep in mind the program will not cover:

• Private nursing
• Services that are provided by members of the same household.
• Disposables e.g. bandages, adult diapers, etc.
• Cosmetic surgeries and
• Chiropractor fees.

Medicaid Dental

What does Medicaid cover on dental

It’s a requirement for most Medicaid-eligible individuals who are below 21 years. It’s considered a required component of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.

There are no minimum requirements for adult dental coverage-most states only provide emergency dental services for adults.

Medicaid cover pregnancy

Pregnancy coverage is mandatory for people earning up to 133 percent of the federal poverty level (FPL).

Most states do provide coverage above this income level.

Some states have also allowed pregnancy-related coverage through CHIP. Under CHIP, coverage is provided to the “unborn child” (during pregnancy and up to two months after the birth of the baby.), which offers a more limited benefit package.

Both programs will provide coverage for:

• Pregnancy care- Prenatal doctor visits and Pre-natal vitamins.
• Labor and delivery.
• Checkups and other postnatal care for the baby.

Medicaid With Spend Down

Individuals under Medicare coverage whose high income would otherwise disqualify them may still get Medicaid.

 This is only allowed when the Cost-sharing (like premiums and deductibles) and other non-covered medical expenses are more than the available income(their income is drawn down).

In such a situation, most states will allow an individual to reduce their countable income by subtracting medical expenses and any cost-sharing from their income to the level that qualifies them for Medicaid.

The term for this process is “spend down.” And most states allow anywhere between 1–6 months.

Medicaid and Food Stamps

Supplemental Nutrition Assistance Program (SNAP), formerly referred to as the food stamp program, provides monthly assistance to low-income households to enable them to buy food needed for good health.

States seeking to expand Medicaid eligibility can sustain enrollment and retention for participants by pairing the program with SNAP. For a household to qualify for SNAP, generally their gross income should be below 130 percent of the poverty line.

In most states, a big percentage of SNAP recipients do qualify for Medicaid. Even in states where SNAP eligibility has been extended to at least 185 percent of the federal poverty level (FPL), still, the majority of SNAP recipients will qualify for Medicaid.

Medicaid with Medicare Dual Eligible

Dual-eligible beneficiaries (“duals”) are low-income earners who enroll in both Medicare and Medicaid. These two programs have overlapping benefits, with Medicare being the primary payer. Medicaid will only cover benefits not provided by Medicare.

The beneficiaries usually enjoy a combination of Medicare (Part A, Part B, or both) and Medicaid (full benefits), Medicare Savings Programs (MSPs), or both.

MSPs will cover Part A premiums, Part A and B deductibles, coinsurance, and copayments, depending on the program.

Dual-eligible people will fall into the following categories;

• “partial duals” or
• “full duals”

The above is dependent on the level of Medicaid benefits for which the person is eligible.

Medicaid Vs CHIP

Similarities of Medicaid and the Children’s Health Insurance Program (CHIP)

• Both are Public insurance programs that take care of children
• They receive joint state and federal matching dollars in funding
• A key source of care and coverage for around 35.9% of Children and Youth with Special Health Care Needs (CYSHCN)

Differences between Medicaid and CHIPs

Bottom line

Apply even when the chances of qualification are low due to your income.

You might still qualify for your state’s program, especially if;

• You are a parent
• Pregnant, or
• Disabled

This program doesn’t have an Open Enrollment Period. Applications can be at any time of the year.