Medicaid Basics: Eligibility and Coverage

Answers to frequently asked questions about Medicaid eligibility, coverage, and denials.

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Medicaid is a program that provides very low-cost or free health care to some adults and children with limited incomes. Medicaid is funded by the federal government and by the states, and each state manages its own Medicaid program. Some states have given the Medicaid program a different name; for example, California’s Medicaid program is called Medi-Cal.

Who Can Get Medicaid?

Eligibility rules for each state’s Medicaid program are different, but there are some common features. In general, you must be low-income and have very few assets to qualify for Medicaid. However, not every low-income person with few assets qualifies for the program. There are several categories of eligibility for Medicaid, such as those who are disabled, pregnant, or over 65.

People with disabilities can qualify for Medicaid if they meet the income and asset requirements. In most states, a person automatically qualifies for Medicaid if they receive SSI.

Pregnant women who meet the income and asset requirements will qualify for Medicaid. Children are automatically covered for one year after they are born to mothers on Medicaid. Many states provide coverage to pregnant women with higher income and assets than is normally allowed for Medicaid eligibility.

Women with breast or cervical cancer can obtain treatment through a special Medicaid program for those diseases. Many states offer this coverage to women at higher income levels.

Most states offer Medicaid to low-income adults with children, although there is not a uniform income standard for that coverage.

Children in households with incomes too high to qualify for Medicaid but not high enough to afford private insurance may be covered by their state’s Children’s Health Insurance Program (CHIP). CHIP covers children whose family incomes are up to $45,000 for a family of four.

An expansion of the Medicaid program is set to take effect on January 1, 2014, according to a provision of the federal Affordable Care Act. Under the Medicaid expansion, adults under 65 years old who have incomes at or below 133% of the poverty level (about $15,000 for an individual) can be eligible for Medicaid, even if they do not have children and are not disabled. However, in June 2012, the U.S. Supreme Court ruled that the federal government cannot force the states to participate in the Medicaid expansion. It is likely that some states will opt out of the expansion.

Do I Have to Be a Citizen to Get Medicaid?

You must be a U.S. citizen or a lawful permanent resident to receive Medicaid. You must show proof of your citizenship or immigration status and identity to qualify for Medicaid. However, there is an exception to the citizenship requirement for people with emergency medical conditions, including pregnant women in labor. Some states offer coverage of prenatal expenses (non-emergency care for pregnant women) regardless of citizenship status.

What Services Does Medicaid Pay For?

Each state can determine what services its Medicaid program will pay for, but some services must be covered. Mandatory covered services include inpatient and outpatient hospital bills, prescriptions, lab fees, long-term care services, transportation to and from medical care, and vision and dental care for children. In addition to the mandatory covered services, some states have chosen to provide Medicaid coverage for things like glasses, hearing aids, physical therapy, mental health services, and hospice care.

Even though Medicaid may pay for these services, it can be hard for a Medicaid recipient to get a certain service, because there may be no provider in the area who accepts Medicaid as payment for the service. For example, in many rural areas of the country, there are no dentists who accept Medicaid, and so children receiving Medicaid may not be able to access dental care.

Medicaid recipients must show that the particular service they want Medicaid to pay for is medically necessary. There is no federal definition of medical necessity, but each state has defined the term as it is used in their Medicaid program. In general, the medical necessity requirement prevents Medicaid recipients from having the program pay for elective treatments and procedures.

How Are Medicaid Services Provided?

Today many Medicaid recipients get their services from managed care organizations, which are private companies that states have hired to deliver medical services according to Medicaid guidelines. Other Medicaid recipients still get “fee for service” Medicaid, meaning that the state itself pays a fee for the medical provider’s service to the Medicaid recipient.

In all states, Medicaid is supposed to be affordable for low-income people, and so services are provided at an extremely low cost, or sometimes free.

How to Apply for Medicaid

To apply for Medicaid, contact your state’s Medicaid agency. You can find the website for your state’s agency by selecting your state from the map at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.html.

If Your Application for Medicaid Is Denied

You have a right to appeal any denial of a Medicaid application. The deadlines and procedures for appealing should be described in your written denial notice from your state's Medicaid office. For more information, see Nolo's article on appealing a Medicaid denial.

Many legal aid offices provide free legal assistance for applicants who have been denied Medicaid. You can find your local legal aid office by selecting your state and county under “Find Legal Aid” at the Legal Services Corporation's website.

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