Medicaid is a federal and state program that provides health care coverage to people who qualify. Each state runs its own Medicaid program, but the federal government has rules that all states must follow.
The federal government also provides at least half of the funding for their Medicaid requirements. Based on federal regulations, states create and run their own Medicaid program to best serve their residents who qualify.
States may choose to provide more services than the federal government requires and they may also choose to provide coverage to larger groups of people. Medicaid provides health care coverage for people who qualify, based on income and the value of what they own. For a quick overview of Medicaid, watch the Medicaid Made Clear video basics.
Medicaid began as part of the Social Security Act of The original law gave states the option of receiving federal funding to help provide health care coverage to children whose families have a low income, their caregiver relatives, people who are blind and people who are disabled.
Over time, the federal government has strengthened the rules and requirements for state Medicaid programs. States can also choose to expand eligibility to other groups, such as people with low income who may or may not have children.
Source: Medicaid. Each state decides the full range of benefits that it covers under Medicaid. Federal law requires that states must provide certain benefits, which are called mandatory benefits.
States may also choose to offer other benefits and services by Medicaid. These are called optional benefits. The chart below shows what are mandatory benefits and what are optional Medicaid benefits. Prescription drug coverage is an optional benefit under federal Medicaid law. But, as of , all states include some form of prescription drug coverage under their Medicaid program.
In general, most enrollees within a state Medicaid program will get prescription drug coverage. Medicaid programs may also cover a variety of different Home- and Community-Based Services HCBS to help people stay living at home and active in the community. The level of support provided is typically based on the needs of the individual. Examples of the types of home health care and residential senior care services provided as part of HBCS programs include:.
Some HCBS services like skilled nursing care and occupational, physical or speech therapy are delivered by qualified and, in some cases, licensed professionals. Other services, such as doing chores around the house and making meals, can be provided by family members, friends or paid caregivers.
Because each state manages its own Medicaid program, eligibility varies from one state to another. If you have questions about qualifying, contact your state Medicaid agency. Or, apply online at the website for your state Medicaid agency to see if you qualify. A Dual Special Needs Plan or dual-eligible health plan is a type of health insurance plan for people who have both Medicaid and Medicare.
Dual Special Needs Plans provide extra help to those who need it. Most dual health plans also give you more benefits and features than you get with Original Medicare.
Learn more about dual health insurance plan benefits. Please note: What dual-eligible plans you can get depends on where you live. View All Benefits Articles. View All Enrollment Articles. Contact us at: TTY: 8 a. Hmm … it looks like your browser is out of date. Update Now. Find the plan you're looking for today. Search for plans by ZIP or state. Find Plans Find Plans.
Eligible for Medicaid and Medicare? Learn about Dual Eligible plans. Select your state. States A to - G Skip to. Over time, Congress expanded federal minimum requirements and provided new coverage options for states especially for children, pregnant women, and people with disabilities.
Following these policy changes, for the first time states conducted outreach campaigns and simplified enrollment procedures to enroll eligible children in both Medicaid and CHIP. Expansions in Medicaid coverage of children marked the beginning of later reforms that recast Medicaid as an income-based health coverage program.
Prior to the ACA, individuals had to be categorically eligible and meet income standards to qualify for Medicaid leaving most low-income adults without coverage options as income eligibility for parents was well below the federal poverty level in most states and federal law excluded adults without dependent children from the program no matter how poor.
The ACA changes effectively eliminated categorical eligibility and allowed adults without dependent children to be covered; however, as a result of a Supreme Court ruling, the ACA Medicaid expansion is effectively optional for states.
Under the ACA, all states were required to modernize and streamline Medicaid eligibility and enrollment processes. Expansions of Medicaid have resulted in historic reductions in the share of children without coverage and, in the states adopting the ACA Medicaid expansion, sharp declines in the share of adults without coverage.
Many Medicaid adults are working, but few have access to employer coverage and prior to the ACA had no options for affordable coverage. Figure 3: Medicaid has evolved over time to meet changing needs. In FY , Medicaid covered over 75 million low-income Americans. As of February , 37 states have adopted the Medicaid expansion. Data as of FY when fewer states had adopted the expansion show that States can opt to provide Medicaid for children with significant disabilities in higher-income families to fill gaps in private health insurance and limit out-of-pocket financial burden.
Medicaid also assists nearly 1 in 5 Medicare beneficiaries with their Medicare premiums and cost-sharing and provides many of them with benefits not covered by Medicare, especially long-term care Figure 4.
Figure 4: Medicaid plays a key role for selected populations. Medicaid covers a broad range of services to address the diverse needs of the populations it serves Figure 5.
In addition to covering the services required by federal Medicaid law, many states elect to cover optional services such as prescription drugs, physical therapy, eyeglasses, and dental care. Medicaid plays an important role in addressing the opioid epidemic and more broadly in connecting Medicaid beneficiaries to behavioral health services. EPSDT is especially important for children with disabilities because private insurance is often inadequate to meet their needs.
Unlike commercial health insurance and Medicare, Medicaid also covers long-term care including both nursing home care and many home and community-based long-term services and supports.
More than half of all Medicaid spending for long-term care is now for services provided in the home or community that enable seniors and people with disabilities to live independently rather than in institutions. Some states have obtained waivers to charge higher premiums and cost sharing than allowed under federal rules. Many of these waivers target expansion adults but some also apply to other groups eligible through traditional eligibility pathways.
Over two-thirds of Medicaid beneficiaries are enrolled in private managed care plans that contract with states to provide comprehensive services, and others receive their care in the fee-for-service system Figure 6. Managed care plans are responsible for ensuring access to Medicaid services through their networks of providers and are at financial risk for their costs.
In the past, states limited managed care to children and families, but they are increasingly expanding managed care to individuals with complex needs. Close to half the states now cover long-term services and supports through risk-based managed care arrangements.
Community health centers are a key source of primary care, and safety-net hospitals, including public hospitals and academic medical centers, provide a lot of emergency and inpatient hospital care for Medicaid enrollees. Medicaid covers a continuum of long-term services and supports ranging from home and community-based services HCBS that allow persons to live independently in their own homes or in other community settings to institutional care provided in nursing facilities NFs and intermediate care facilities for individuals with intellectual disabilities ICF-IDs.
This is a dramatic shift from two decades earlier when institutional settings accounted for 82 percent of national Medicaid LTSS expenditures.
Figure 6: Over two-thirds of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs. A large body of research shows that Medicaid beneficiaries have far better access to care than the uninsured and are less likely to postpone or go without needed care due to cost. Other states, such as California, Hawaii and Kansas, require seniors to use all or nearly all of their income for institutional long-term care before Medicaid kicks in.
Fortunately, there are other ways for individuals who have substantial medical needs to qualify for Medicaid. Since Medicaid is never simple, there are also a number of exemptions. The American Council on Aging provides a state-by-state eligibility guide. You can visit MedicaidPlanningAssistance. Institutional Medicaid only pays for skilled nursing if individuals need this level of care. Most states require seniors to complete a functional needs assessment as part of the application process.
This assessment typically takes 45 minutes to an hour to complete. These answers are then scored and used to determine an overall rating. To qualify for Institutional Medicaid or Long-Term Services and Supports that are covered by Medicaid waivers, applicants typically must require assistance with at least two activities of daily living. If you think you may qualify for Medicaid, you must apply for coverage in your primary state of residence. Benefits are available to U. Out-of-state coverage is limited unless you experience a life-threatening emergency or are unable to access necessary services in your home state.
The only way to see if you qualify for Medicaid is by completing an application. However, before you do, consider working with a Certified Medicaid Planner CMP to ensure the best chances for success. They must meet strict standards for education and work experience before they can sit for this exam. CMPs include attorneys, accountants, social workers, financial advisors and geriatric care managers.
Some CMPs charge for their services, while other organizations offer free assistance, thanks to private donations and community block grants. You can find a professional in your community by calling or contacting your local senior center, legal aid society or Area Agency on Aging. The American Council on Aging also offers a free service that can check your eligibility and match you with a qualified advisor before you need long-term care.
There are a few ways that Medicaid can help with the cost of long-term care:. To receive long-term care benefits, you must require a nursing home level of care as determined by a functional needs assessment that gauges your ability to perform activities of daily living, such as cooking, bathing, dressing and toileting. Fortunately, many states offer spend-down programs that allow medically needy adults to qualify for Medicaid if they use excess income to pay for qualifying medical bills.
States that offer a medically needy qualification pathway must also permit residents to establish a Qualified Income Trust, also called a Miller Trust. Approximately 36 states provide this qualification option to help residents who need long-term care. Waivers were first introduced in through section c of the Social Security Act, and many programs still bear this title.
Today, there are more than waiver programs available in 47 states. Collectively, they cover more than 1. Waivers are important because, normally, Medicaid only covers long-term services and supports that are provided in licensed health care institutions, such as nursing homes. Waivers let beneficiaries receive these services at home or in another community-based setting, such as an assisted living facility. However, these programs also benefit seniors who want to age in place and remain in comfortable surroundings, which creates a win-win for the government and the public.
There are several types of HCBS waivers :. Yes, Medicaid is usually free. Although states are permitted to require a share of cost , there are usually no premiums, deductibles or copays with Medicaid since this program is intended for low-income families and individuals with very high medical bills.
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