An Overview of Medicaid

is a federal program that works in conjunction with state governments to provide residents with low-cost or free health care coverage.

In general, the benefits of Medicaid are provided to low-income households, pregnant women, individuals with disabilities, senior citizens and children in the United States.

A majority of the Medicaid program is regulated and operated by state governments, but there are certain federal guidelines that must be followed. Costs and coverage can vary drastically from state to state, but there are minimum coverage requirements established by the federal government.

Different Medicaid programs can cover the costs of your healthcare in various ways. For example, some states may pay for the costs directly while others will work with private insurance agencies in order to fund your coverage.

Certain states have expanded their Medicaid income eligibility limits in order to provide coverage for all residents who are living below a certain income level. Medicaid can also have a different name depending on the state. For instance, Vermont calls the program Green Mountain Care while South Carolina refers to it as Healthy Connections.

Medicaid Basics

The income requirements to qualify for Medicaid coverage can differ between each state. Some states may have expanded limits which will allow you to qualify based on your income, while others may have additional program qualification requirements.

Some other factors that can be considered for Medicaid eligibility include household size, age, disability and more.  If you are unsure whether or not you qualify for Medicaid health care coverage, you can contact your state’s Medicaid office for more information.

How to Apply for Medicaid

If you believe that you are eligible for your state’s Medicaid coverage, you can apply at any time of the year. This is because Medicaid does not have an open enrollment period for applicants and program members.

Applicants have two primary methods of applying for Medicaid, either via the Health Insurance Marketplace or their state’s Medicaid agency. Medicaid provides program participants in the state with comprehensive health care coverage and benefits, which makes Medicaid the preferred option for many residents.

In a few states, the government has elected to expand Medicaid coverage to all residents of their states with incomes that are 133 percent below the U.S. poverty level. It is important to note that not all states use this same percentage for eligibility.

Residents who live in states that have not expanded their Medicaid coverage may need to explore other alternative government health care programs. A few helpful options are the Children’s Health Insurance Program (CHIP) or shopping on the Health Insurance Marketplace. States are given the option to expand their Medicaid coverage at a later time if they wish to.

What health services are covered by Medicaid?

Although each state is given the option to set up its own Medicaid program, there are some benefits that the federal government requires them to offer. The mandatory benefits that are available in all states under the Medicaid program include:

  • Inpatient and outpatient hospital services.
  • Nursing facility services.
  • Home health services.
  • Rural health clinic services.
  • Physician services.
  • Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services.
  • X-Ray and laboratory services.
  • Family planning, nurse midwife, freestanding birth center, family nurse practitioner and pediatric services.
  • Pregnant women’s tobacco cessation counseling.
  • Transportation to and from medical services and appointments for eligible beneficiaries.
  • Federal qualified health center services.

There are some additional optional benefits that states can elect to offer Medicaid recipients. Although these services are not offered in every state, they can be beneficial for eligible program members. Some common optional Medicaid benefits include:

  • Prescription drugs.
  • Physical therapy.
  • Occupational therapy.
  • Clinical services.
  • Speech, hearing and language disorder services.
  • Respiratory care services.
  • Other diagnostic, screening and rehabilitative services.
  • Podiatry services.
  • Optometry services.
  • Dentures.
  • Prosthetics.
  • Eyeglasses.
  • Chiropractic services.

Medicaid Rules You Should Be Aware Of

Certain Medicaid types only offer limited benefits such as outpatient, tuberculosis and emergency services. They may also offer family planning services in some states. Beneficiaries who only have limited coverage under Medicaid can apply for comprehensive medical health care coverage through Medicaid or the marketplace.

Former foster children are granted Medicaid coverage in every state until they reach 26 years of age if the meet certain program requirements. For example, the former foster child will be eligible if they received Medicaid benefits while they were in the foster care system on their 18th birthday.

Additionally, if the former foster child was covered by Medicaid when they aged out of the foster care system after they reached at least 18 years of age, they will also be covered.

What if I have been denied from the Medicaid program?

If an applicant has been denied from Medicaid coverage due to missing or incorrect information or documents, they can file an appeal with their state’s Medicaid agency. In order for an appeal to succeed, applicants are required to provide any documents or information that needs to be corrected from their initial application. If the information is successfully corrected, the applicant may be accepted into the Medicaid program.

Applicants who have been denied coverage through Medicaid still have the option to purchase a private health insurance plan through the health insurance marketplace. In some circumstances, they may qualify for a premium tax credit and additional savings on out-of-pocket costs which can leave them paying under $75 per month for health care coverage.

In certain states, when you have been denied Medicaid coverage, you will be recommended to apply for private insurance. To make the process easier, some state Medicaid agencies will provide you with a pre-filled application containing the information that you provided to the Medicaid agency.

For applicants who have been denied because Medicaid hasn’t been expanded in their state, the options are far more limited. These applicants may not be eligible to receive any tax credits or savings on a private marketplace health insurance plan. These individuals are encouraged to visit a community health center near them for their health care needs. They will be able to provide medical services on a sliding scale of availability.