Learn About Medicaid

Medicaid is a joint program of the federal and state governments that provides low-cost or free health care coverage to millions of low-income people, pregnant women, people with disabilities, senior citizens, families and children in the U.S.

There are federal guidelines to which Medicaid programs must adhere, although costs and coverages may vary between states. Different Medicaid programs pay for your health care differently, with some programs paying for it directly and others utilizing private insurance agencies to provide coverage. In certain states, Medicaid has been expanded to cover all residents living below a certain income level. Medicaid goes by different names in different states, such as Green Mountain Care in Vermont, Healthy Connections in South Carolina or Medical Assistance Program in Virginia.

Income qualifications for Medicaid vary from state to state. Furthermore, if the state you live in has not yet expanded its Medicaid program, you may not necessarily be able to qualify based solely on your income. Your state may have additional qualifications regarding such factors as household size, age and disability, among others, to get Medicaid. The only way to find out for sure if you qualify for Medicaid and other government health care programs in your state is to apply for it.

How to Apply for Medicaid

Medicaid does not have an open enrollment period, meaning you can apply for it at any time throughout the year. There are two main ways to apply for Medicaid. You can apply via the Health Insurance Marketplace or the Medicaid agency of your state. Note, if you meet the qualifications for Medicaid, you are not eligible to get a discount on a health insurance marketplace plan and must, therefore, pay full price if you opt for a marketplace plan over Medicaid. Medicaid offers comprehensive coverage and benefits for many state residents, so many applicants would prefer Medicaid assistance. In some states, Medicaid has been expanded to cover all people with a household income 133 percent below the U.S. poverty level, although some states use a different percentage. For those states that did not choose to expand Medicaid coverage, you can explore other government options, such as the Children’s Health Insurance Program (CHIP) or the Health Insurance Marketplace, depending on your household’s needs. Although a state may not currently have the Medicaid expansion, the state may choose to implement the expanded coverage at a later date.

What does Medicaid cover?

There are many mandatory benefits all Medicaid programs must offer. Beyond these covered services, different states may also opt to provide additional, optional benefits. Mandatory benefits available in all states under Medicaid include the following services:

  • Inpatient and outpatient hospital services.
  • EPSDT – Early and Periodic Screening, Diagnostic and Treatment Services.
  • Nursing facility, home health, rural health clinic and physician services.
  • X-ray and laboratory services.
  • Family planning, nurse midwife, freestanding birth center and certified family nurse practitioner and pediatric services.
  • Pregnant women’s tobacco cessation counseling.
  • Federal qualified health center services.
  • Transportation to and from medical services for qualifying beneficiaries.

The optional benefits a state can choose to cover through its Medicaid program are vast and varied. Some optional benefits can include physical therapy and dental services. If you qualify for Medicaid in your state and require medical services, it is well worth checking out whether your Medicaid coverage might pay for most or all of those services.

Learn the Medicaid Rules to Know

Some types of Medicaid offer only limited benefits, paying solely for outpatient hospital service, tuberculosis services, emergency services and family planning, but little to nothing else. If you have only limited coverage under Medicaid, you are allowed to apply for comprehensive medical coverage through either Medicaid or the marketplace. When asked in the application process whether you presently have health insurance coverage, click the box stating “None of the above.”

Former foster children have guaranteed Medicaid coverage in all states until they reach 26 years of age, if they meet one of the following requirements:

  • The former foster child received Medicaid benefits while in the foster care system on their 18th birthday.
  • The former foster child had Medicaid coverage when they aged out of the foster care system after they reached 18 years of age or older.

If, however, the foster child takes residence in a different state, the new state may not provide Medicaid coverage.

Contact the Medicaid agency of your state if you did not receive your enrollment card or are not certain whether you or a particular medical product or service are covered. Contact Medicaid as well if you cannot find a physician who takes Medicaid or cannot get an appointment. If you have a change in your life that may influence your Medicaid eligibility, you are also expected to inform your state’s Medicaid agency of the change.

What if I have been denied Medicaid?

If you have been turned down for Medicaid coverage, you can still purchase a private plan through the health insurance marketplace. You may be eligible for a premium tax credit and out-of-pocket cost savings and could pay under $75 per month for coverage. The other options available to you vary depending on the circumstances of your denial of Medicaid coverage. If your state informed you in a notice that you simply are not eligible for Medicaid, the state will generally submit your information to the marketplace. The marketplace will, then, contact you to explain how you can apply for a private health plan. For your convenience, you will receive a pre-filled application to submit containing the information you provided to your state’s Medicaid agency.

If, on the other hand, you were denied Medicaid coverage because your state has not yet expanded its Medicaid coverage, your options are sparse, and you may simply not qualify for any savings on a private marketplace health plan. Other ways to find affordable health care include visiting a community health center near you. Funding to these centers has been expanded under federal law, and most provide medical services on a sliding scale. If your income increases, you may qualify for Advance Premium Tax Credit (APTC) payments that allow you to enroll in a marketplace health plan right away through a Special Enrollment Period (SEP). You may qualify as medically needy depending on your situation and your state. This type of program offers assistance to eligible applicants with high health care costs who otherwise do not qualify for Medicaid services.

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