Health Insurance

Medicaid & Children's Health Insurance Program

An Overview of Medicaid Eligibility and Benefits

Covering more than 72 million Americans, Medicaid is the largest health insurance provider in the United States. The program, created under the Social Security Amendments of 1965, is available to low-income individuals in the United States, the District of Columbia, and U.S. territories. It is a collaboration between federal and state governments to provide coverage for basic health care. Understanding how it works will help you to make the most of its benefits.

Who Can Get Medicaid?

Many people with low incomes would be unable to afford health insurance without government assistance. This is where Medicaid comes into play. The U.S. Department of Health and Human Services determines the federal poverty level (FPL) every year, and these values are used to set the eligibility standards for Medicaid.

Not everyone is eligible for Medicaid, however, even if they have low income.

They also must fall into certain categories that meet federal and state requirements. The Centers for Medicare and Medicaid Services mandates that the following groups be covered by Medicaid in all states:

  • Children newborn to five years old with family incomes up to 133 percent of the FPL
  • Children six to 18 years old with family incomes up to 100 percent of the FPL
  • Elderly individuals with an income up to 75 percent of the FPL
  • Families with dependent children with an income up to 11 to 68 percent of the FPL (based on a state's Aid to Families with Dependent Children income threshold)
  • Individuals with disabilities on Social Security Insurance (SSI) with income up to 75 percent of the FPL
  • Pregnant women with incomes up to 133 percent of the FPL

The federal government sets the standard but individual states can choose to expand coverage beyond these limits. For example, they can increase income thresholds to include more people.

How the Affordable Care Act Affects Medicaid Eligibility

The Affordable Care Act, or Obamacare, had a significant impact on Medicare eligibility when it was enacted in 2010. To increase healthcare access to millions of Americans, Obamacare offered Medicaid Expansion to states.

In exchange for federal funding, states agreed to expand Medicaid coverage to anyone with incomes up to 133 percent of the FPL, regardless of other factors. (Childless individuals would no longer be excluded from coverage.)  

At the present time, 32 states and the District of Columbia have pursued Medicare Expansion. These states will receive federal funding over the first three years of their expansion and then 90 percent of those expansion costs through 2022. The remaining states continue to follow the traditional Medicaid eligibility guidelines.

How Immigration Affects Medicaid Eligibility

Being an American citizen assures that you can get Medicaid coverage as long as the other requirements are also met. The same cannot be said for those with immigrant status.

States decide whether or not they will offer coverage to people who are not yet U.S. citizens, in which case the federal government sets these guidelines to follow. Legal immigrants residing in the country prior to 1996 may be eligible for full benefits. With the exception of those on SSI, legal immigrants entering the country after 1996 can only become eligible for full benefits after five years of residency. Immigrants who have entered the country illegally may be eligible for emergency services only, not the full Medicaid benefit.

What Does Medicaid Cover?

Medicaid does not necessarily cover everything but it covers a lot. The federal government requires that certain services be offered to all Medicaid beneficiaries. These mandatory services include the following:

  • Care provided in community health centers and rural health clinics
  • Care provided in nursing facilities for people 21 years of age and older
  • Care provided by physicians, nurse midwives, and nurse practitioners
  • Early and periodic screening, diagnostic, and treatment (EPSDT) services for people under age 21 years of age
  • Family planning services and supplies
  • Home health care for people eligible for nursing facility services
  • Laboratory and x-ray services
  • Transportation for medical reasons

However, each state has the option to expand on those services. And they often do. These optional services may include but are not limited to:

If you are eligible for or are currently on Medicaid, you can learn more information about what your state program covers on the Medicaid.gov website.

The Difference Between Medicaid and Medicare

Medicaid and Medicare may sound and look a lot alike, but don't be fooled.

Both health care programs may be regulated by the Centers for Medicare and Medicaid Services, but there are a lot of differences between the two programs.

While Medicare is a federally run program, Medicaid is run by states. Both programs offer care to the elderly and to those with disabilities, but only Medicaid offers care to low-income individuals of all ages regardless of their health status. Medicare limits nursing home care to short-term recovery after a hospital stay, but only Medicaid provides long-term nursing home care to its beneficiaries.

More than eight million people are eligible for both Medicaid and Medicare. These people are referred to as dual eligible. They get the best of both worlds, so to speak. Medicaid helps them to pay for services that Medicare doesn't cover.

How to Sign Up for Medicaid

Enrolling in Medicaid can be done easily online at Medicare.gov. Alternatively, you can contact your local Medicare office to apply by phone or to schedule an in-person appointment. If you are eligible, you will want to sign up as soon as possible to make the most of the benefit.

Sources:

Medicaid - A Primer: Key Information on the Nation’s Health Coverage Program for Low-Income People. The Kaiser Commission on Medicaid and the Uninsured. https://kaiserfamilyfoundation.files.wordpress.com/2010/06/7334-05.pdf. Published March 2013.

Medicaid and CHIP Application, Eligibility Determination, and Enrollment Data. Medicaid.gov website. https://www.medicaid.gov/medicaid-chip-program-information/program-information/medicaid-and-chip-enrollment-data/medicaid-and-chip-application-eligibility-determination-and-enrollment-data.html.

Medicaid Financing. National Association of Medicaid Directors website. http://medicaiddirectors.org/key-issues/medicaid-financing/.

Obamacare Medicaid Expansion. Obamacare Facts website. http://obamacarefacts.com/obamacares-medicaid-expansion/.

Poverty Guidelines. U.S. Department of Health and Human Services website. https://aspe.hhs.gov/poverty-guidelines. Published January 15, 2016.

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