What Does the Term 'Medically Needy' Mean?

Have You Been Denied Medicaid Because Your Income is Too High?

Medically needy programs cover pregnancy.
Medically needy programs cover pregnancy. Nils Hendrik Mueller/Getty Images

The term medically needy is a distinction used for individuals who fall into a determined specific category, or criteria, of mandatory Medicaid eligibility established by the federal government. More than 40 states plus the District of Columbia operate medically needy programs, which allow them to provide Medicaid to certain groups of individuals who are not otherwise eligible for Medicaid.

If you have been denied Medicaid coverage because your income is too high, you might qualify as a "medically needy" individual based on your income and health status.

The Medically Needy program is intended for individuals who have too much income to oterhwise qualify for Medicaid. From the Partnership for Prescription Assistance:

"The Medically Needy program is a Medicaid program for people who have too much income or assets are over the limits for Medicaid, Some people call it the “share of cost” program. The Department of Children & Families (DCF) determines eligibility for the Medically Needy Program."

Medicaid

Medicaid is an insurance program specifically designed for low income and needy individuals. Medicaid provides health coverage specifically for younger children, certain senior citizens, and individuals with disabilities.

Medicaid is funded directly by the Federal government in junction with all fifty individual states.

If your state offers a medically needy program, it must cover:

  • Pregnant women
  • Children under 18

Your state also has the option to cover:

  • Children up to 21
  • Parents and other caretaker relatives
  • Elderly individuals

Individuals with disabilities

Medicaid Benefits

  • Each state is required to cover certain particular health benefits. Benefits that the states are required to cover by the federal government are known as mandatory benefits. Such mandatory benefits include:
  • Services of a physician, a nurse midwife, and nurse practitioner, if necessary.
  • Necessary laboratory or x-ray services
  • Outpatient and inpatient hospital services
  • Services, supplies, and information regarding family planning
  • Access to services within various community health centers and rural health clinics
  • Various other services and state options

Your state’s medically needy program may also expand coverage to people who “spend down” by incurring medical expenses so that their income falls below a state-established medically needy income limit. The opportunity to spend down may be particularly important to you if you are elderly and reside in a nursing home. Also, children and adults with disabilities who live in the community may have high prescription drug, medical equipment, or other health care expenses.

The Affordable Care Act, passed in March 2010, will significantly expand the number of people in the country who are eligible for Medicaid. This expansion may cover many of the people who currently are in a medically needy program.

To find the Medicaid Agency in your state, use the interactive map from the National Association of State Medicaid Directors.

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