Medicaid is a means- tested, federally and state-funded health and medical program for low-income individuals and families. Unlike Medicare, people of all ages can enjoy the benefits of Medicaid. Each state-based program must provide the following basic services: inpatient hospital services, outpatient hospital services, prenatal care, vaccines for children, physician services, nursing facility services for persons aged 21 or older, family planning services and supplies, rural health clinic services, home health care for persons eligible for skilled-nursing services, laboratory and x-ray services, pediatric and family nurse practitioner services, nurse-midwife services, federally qualified health-center (FQHC) services and ambulatory services, and early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21.
Every state has the option of providing additional services, the most common of which are diagnostic services, clinic services, intermediate care facilities for the mentally retarded, prescribed drugs and prosthetic devices, optometrist services and eyeglasses, nursing facility services for children under age 21, transportation services, rehabilitation and physical therapy services, and home and community-based care to certain persons with chronic impairments. Similarly, each state has its very own eligibility guidelines. For example, the Affordable Care Act had a provision that all citizens and legal residents with income up to 133% of the poverty line would qualify for Medicaid regardless of the which state they live in. the Supreme Court, however, ruled that states could either adopt or opt out of the provision without detriment to their previous levels of Medicaid funding.
Whether or not you qualify for Medicaid depends on factors like income and household size and on whether your state is expanding Medicaid or not. States that expand Medicaid receive extra funding to cover adults under 65 years of age who earned up to 133% of the federal poverty level. If you live in such a state, you’ll most likely qualify if you earn up to $16,104 a year for 1 person or $32,913 for a family of four. If not, your alternatives are reduced and will depend on your income. More than 100% of the poverty level will get you a private insurance plan in the Marketplace and maybe lower costs based on household income and size. Less than about $11,490 (single person) or $23,550 (family of 4) may not get you lower private insurance costs.
Twenty-six states are implementing Medicaid expansion in 2014. They are:
7. District of Columbia
17. New Jersey
18. New Mexico
19. New York
20. North Dakota
23. Rhode Island
26. West Virginia
Not moving forward at this time:
12. North Carolina
14. South Carolina
15. South Dakota
3. New Hampshire
People are encouraged to apply for Medicaid regardless of whether their state is expanding Medicaid or not, which they can do online at the Marketplace, or by contacting their state´s Medicaid office or website. Depending on your individual circumstances and your state’s existing rules, you may still find suitable coverage. Additionally, Medicaid has an outreach program that aims to find and enroll individuals who qualify for Medicaid benefits but have not become beneficiaries yet.
In addition to the optional eligibility groups that each state decides upon, there are also mandatory eligibility groups that all states must cover. Mandatory –or categorically needy- groups include individuals who meet Aid to Families with Dependent Children (AFDC) program requirements effective in their state on 7/16/96, children under 6 whose family income is at or below 133% of the poverty level, pregnant women with family income lower than 133% of the poverty line, supplemental security income recipients, and certain Medicare beneficiaries (see a complete list of mandatory and optional groups here).
Medicaid beneficiaries are not given money. Instead, each state has a program that sends payments to health care providers based on a fee-for-service agreement or prepayment arrangements, i.e., health maintenance organizations, or HMO’s. Then the Government reimburses each state a percentage of program expenditures, known as Federal Medical Assistance, or FMAP. The FMAP per state is required by law to be range between 50% and 83%, though poor states get a bigger share than rich ones. Each state may enforce cost sharing measures such as charging premiums and out-of-pocket costs including copayments, coinsurance, and deductibles. Though out-of pocket costs are limited, states can target relatively higher income people for higher charges. Conversely, some Medicaid beneficiaries are exempt from cost sharing, namely pregnant women, children under 18 years of age, and hospital or nursing home patients expected to contribute most of their income to institutional care. All beneficiaries are excluded from copayments for emergency and family planning services.
Related Read: What are the parts and costs of Medicare?