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Medicaid | Eligibility, Benefits, Services & How to Apply

Medicaid


What is Medicaid ?


Medicaid Program is a combined federal/state program. Medicaid is a program in the United States that helps with health care costs for some people with limited income and resources. Medicaid was created in 1965, providing health coverage under the program to children, pregnant women, parents, people with disabilities, senior citizens, and low-income individuals. Each state Children's Health Insurance Program (CHIP) and Medicaid agency has full responsibility for all aspects of the operation and administration of Medicaid programs in their state, including determining enrollment and eligibility for their program. 

Medicaid is described by the Health Insurance Association of America as a government insurance program for individuals of all ages. Medicaid is the largest source of funding for health and medical services for low-income people. This program is jointly funded by the state and federal governments and managed by the states. Individuals must be U.S. citizens or eligible noncitizens to receive Medicaid benefits, and the program can include people with disabilities, low-income adults, and their children. Medicaid improves health insurance coverage, health outcomes, access to health care, economic benefits to health providers, and the financial security of recipients.

Medicaid provides benefits that are not normally covered by Medicare, including personal care services and nursing home care. Medicaid and Medicare The main difference between these two programs is that, Medicare provides health coverage for the elderly and Medicaid covers the cost of health care for low-income people. There are also dual health plans for people who have both Medicare and Medicaid.

Features of Medicaid 


  • In all states in the United States, Medicaid provides coverage for low-income people/families, pregnant women, people with disabilities, children, and the elderly.
  • For your care, Medicaid programs use private insurance companies to provide coverage but some Medicaid programs pay directly.
  • In some states, all adults who are below a certain income level are covered.
  • The cost and coverage of Medicaid programs can vary from state to state. But states must follow federal guidelines.
 

Benefits of Medicaid


There are two types of Medicaid coverage. Community Medicaid helps for those with little or no medical insurance, and Medicaid nursing home coverage helps pay for the cost of living in a nursing home for those people.

States administer and establish their own Medicaid programs and determine the scope, amount, type and duration of services within broad federal guidelines. Under federal law, states are required to provide certain mandatory benefits, but states are allowed the option of covering other optional benefits. Essential benefits include physician services, inpatient and outpatient hospital services, X-ray laboratory services, home health services and other services. Alternative benefits include physical therapy, case management, prescription drugs, and occupational therapy services. Following are some mandatory benefits and optional benefits :

Mandatory Benefits :

  • Inpatient hospital services
  • Outpatient hospital services
  • EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
  • Nursing Facility Services
  • Nurse Midwife services
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Tobacco cessation counseling for pregnant women
  • Certified Pediatric and Family Nurse Practitioner services
  • Freestanding Birth Center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care

Optional Benefits :

  • Prescription Drugs
  • Clinic services
  • Physical therapy
  • Occupational therapy
  • Speech, hearing and language disorder services
  • Respiratory care services
  • Podiatry services
  • Optometry services
  • Dental Services
  • Dentures
  • Prosthetics
  • Eyeglasses
  • Chiropractic services
  • Other practitioner services
  • Private duty nursing services
  • Personal Care
  • Hospice
  • Case management
  • Other diagnostic, screening, preventive and rehabilitative services
  • Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
  • Services in an intermediate care facility for Individuals with Intellectual Disability
  • State Plan Home and Community Based Services- 1915(i)
  • Self-Directed Personal Assistance Services- 1915(j)
  • Community First Choice Option- 1915(k)
  • TB Related Services
  • Inpatient psychiatric services for individuals under age 21
  • Other services approved by the Secretary*
  • Health Homes for Enrollees with Chronic Conditions – Section 1945

What is the Eligibility Criteria for Medicaid ?


Contact your state's Medicaid office to confirm your eligibility under Medicaid. Many states have expanded their Medicaid programs to cover (low-income) adults. In general, it depends on a combination of age, income level, number of people in your family and if you are pregnant or have a disability. You must be a United States (U.S.) citizen or have a satisfactory immigration status to be eligible for full benefits. You can visit HealthCare.gov to determine your eligibility for Medicaid or other health insurance options.

Medicaid Eligibility :

To receive federal funding, states must cover certain "mandatory" populations :
  • Children under the age of 18 in households earning less than 138 percent of the federal poverty line.
  • Few parents or caregivers with very low incomes.
  • Those who are pregnant and whose income is less than 138 percent of the poverty line.
  • People with disabilities and seniors who receive cash assistance through the Supplemental Security Income Program (SSI).

States may also receive federal Medicaid funds to cover "optional" populations, the groups listed above include :
  • People whose income exceeds the limits of "mandatory" coverage
  • Senior citizens and disabled people who are not getting SSI and whose income is below poverty line
  • Medically needy people (whose income exceeds the state's regular Medicaid eligibility limit but who have high medical expenses)
  • Other people with higher income who need longer services and supports.

What is the Income Level for Medicaid ?


The income level to qualify for Medicaid depends on your state in which you live. You may qualify based on income, if your state has expanded Medicaid, See Medicaid Eligibility Based on Income Level.

If your state has not expanded Medicaid, you may qualify based on the current rules in your state. Different states have different rules and may take into account age, family size, income, disability, family status, and other factors.

What Services Does Medicaid Cover ?


Medicaid programs cover essential services such as home health services, hospital and physician care, nursing facilities for adults, laboratory and X-ray services. States need to provide a more comprehensive set of services for children under the age of 21. States may also cover some additional services such as vision services, dental care, hearing aids and personal care for vulnerable seniors and people with disabilities.

About three-quarters of Medicaid spending pays for services such as hospital care, prescription drugs and physician services, and the remainder pays for long-term care services and nursing homes. Medicaid covers the cost of long-term care support and services for about 50 percent and more than 60 percent of all nursing home residents. State Medicaid programs pay for covered services to nursing homes, doctors, hospitals, and other health care providers.

How to Apply for Medicaid ?


Medicaid provides free or low-cost health coverage to low-income people or families, children, the elderly, pregnant women, people with disabilities, and millions of Americans. Some states have expanded their Medicaid programs.

If you don't qualify for Medicaid based on income, you should still apply. You may qualify for your state's program if you have children, are disabled, or are pregnant. Medicaid does not have an open enrollment period, so you can apply for Medicaid at any time of the year.

If you want to apply under this program, there are two ways to Medicaid application :

1) Through the Health Insurance Marketplace :

When you submit the Marketplace application, you will also know whether you are eligible for an individual insurance plan with savings based on your income. The plans may be more affordable than you think.

2) Through State Medicaid Agency :

You can also apply to your state Medicaid agency. You must be a resident of the state in which you are applying. Select your state below for contact information for your state's Medicaid agency.
Contact your state Medicaid agency.

How to Check the Status of Your Medicaid Application ?


You contact the office where you applied for Medicaid. Please contact your state for all state-related Medicaid questions. If you don't have contact information available for your state, you can find that information at the State Medicaid Link.

How to File a Complaint About Medicaid ?


You can file a complaint if you have a problem with Medicaid services. This program is administered by each state, so contact your state's Medicaid program to report your problem.

Medicaid Number (Helpline)


To help you receive a timely response, please contact your state Medicaid agency with any questions you may have.

How to Contact CMS ?


Medicare and Medicaid Services is equipped for general policy guidance, information systems, grants and reimbursement-related technical assistance.

Contact Center for Medicare and Medicaid Services (CMS) : 
7500 Security Boulevard, Baltimore, Maryland 21244-1850
  • Local : 410-786-3000
  • Toll-Free : 877-267-2323
  • TTY Toll-Free : 800-877-8339
  • TTY Local : 410-786-0727
  • Mail : Medicaid.gov@cms.hhs.gov
For Medicaid :
  • Toll-Free : 877-267-2323
  • TTY : 866-226-1819
  • Website : www.Medicaid.gov
For Medicare :
  • Toll-Free : 800-633-4227
  • TTY : 877-486-2048
  • Website : www.Medicare.gov
Healthcare.gov (Marketplace) :
  • Toll-Free : 800-318-2596 
  • TTY : 855-889-4325
  • Website : www.HealthCare.gov

FAQ's


What if I have Medicaid now, but I have only limited benefits ?

You can fill out an application through the Health Insurance Marketplace if you have limited Medicaid coverage and find out if you qualify for comprehensive coverage through Medicaid with income-based savings. are or not. Some limited types of Medicaid coverage pay only for :
  • emergency medicaid
  • Family planning
  • outpatient hospital services
  • Tuberculosis Services

What assistance is available through Medicaid ?

Medicaid offers low-cost or free Medicare benefits to eligible people:
  • Children
  • Low income adults
  • People 65 years of age or older
  • Pregnant women
  • People with disabilities

When to Contact a State Medicaid Agency ?

Contact your state Medicaid agency with any questions on the following :
  • Coverage and Services
  • Medicaid eligibility
  • Medicaid claim
  • Lien and Third Party Liability (Other Insurance)
  • Lost Medicaid Card/Replacement
  • provider enrollment
  • Medicaid Application Status
  • Finding a Medicaid Provider

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