Medicaid Insurance Coverage and Eligibility 2017 Guide

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Medicaid Insurance

Medicaid is a United States health care program for certain individuals that is provided jointly by the federal government and state governments. Although Medicaid insurance has a similar name to Medicare, also referred to as Part A and Part B, and both are government health care programs, they serve different purposes. Medicaid is primarily for people who have very low incomes and could not otherwise afford to pay medical expenses.

Medicaid insurance overview

Along with the Children’s Health Insurance Program (CHIP), Medicaid covers more than 72.5 million individuals, or nearly one quarter of all Americans.1 Medicaid is generally for low-income families and covers children, pregnant women, people with disabilities, and more. The costs of Medicaid are funded through both federal and state sources, including taxes paid by Americans.2

Differences between Medicare and Medicaid

Medicaid is not the same as Part A and Part B. The later is a federally managed program for individuals age 65 and older and those with certain disabilities or conditions. Medicaid is managed by state governments and regulated by the federal government, and it generally covers lower income Americans. Because Medicaid is state managed, some rules—such as who is eligible—vary depending on where you live.

Some health services that Part A and Part B doesn’t cover are eligible for coverage under Medicaid insurance. Read the next section for more details.

What it covers

Although each state maintains its own program, some coverage is mandated by federal law. Here are the types of care covered:

  • Hospital services, inpatient and outpatient
  • Nursing facilities
  • Home health care
  • Doctor visits and services
  • Rural health clinics
  • X-rays and laboratory tests
  • Family planning
  • Ambulance transportation
  • Counseling for quitting tobacco

In addition to these mandatory benefits, some states cover additional optional benefits like the following:

  • Prescription drugs
  • Dental care
  • Vision services and eyeglasses
  • Physical, speech, and occupational therapy
  • Rehabilitation services
  • Foot care
  • Dentures
  • Hospice
  • Chiropractic services

Read this complete list of mandatory and optional Medicaid benefits.

Eligibility Guidelines

These are the main types of people and families who might become eligible for Medicaid:

  • Lower income individuals and families
  • Pregnant women and their children
  • Elderly individuals
  • People who get Supplemental Security Income (SSI)

Some states cover more people, such as those who are getting long-term home or community services and children in foster care.

The Affordable Care Act (ACA), also known as “Obamacare,” expanded coverage for Medicaid and CHIP in states that adopted the new programs.3 For most people, to determine if you are eligible, the government uses your Modified Adjusted Gross Income (MAGI).4 To find out if you qualify for Medicaid and apply, visit the Health Insurance Marketplace or contact your state insurance department.

Some rules apply for you to be legally eligible. In general, both of the following criteria must apply:

  • You are a U.S. citizen or lawful permanent resident.
  • You are a citizen of the state where you’d like to receive benefits.

Finally, certain “medically needy” people who have significant health needs but earn too much to qualify may be eligible for the program.

How it works with Part A and Part B coverage

Some people qualify for both. This is called “dual eligibility,” and around 9 million Americans fall into this category.5 Common dual eligible beneficiaries are people older than 65 with low incomes and people younger than 65 with disabilities.

Having both Medicaid and Part A and B means that most of your necessary health care costs will be covered. People who qualify for dual eligibility often have difficult and expensive health conditions, which require high amounts of coordination and help paying for the costs of care.

Medicaid and other insurance

  • If you qualify for both, you may choose to enroll in a Part D prescription drug and/or Part C plan and keep your Medicaid coverage.
  • If you are dual eligible, you’ll automatically qualify for extra help, or government assistance paying your Part D prescription drug expenses.
  • Medicaid always pays secondary to Medicare or other types of health coverage.

Sources:

1 Medicaid.gov, “Eligibility
2 Medicaid.gov, “Financing & Reimbursement
3 Medicaid.gov, “Eligibility
4 CMS, “MAGI: Medicaid and CHIP’s New Eligibility Standards
5 Kaiser Family Foundation, “Dual Eligible

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