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What is Medicaid? What Does Medicaid Cover?

What is Medicaid

Medicaid 3

Medicaid offers health coverage to more than 65 million Americans, including eligible low-income adults, pregnant women, children, elderly adults, and persons with disabilities. This program is administered by states, according to the federal requirements. Medicaid is funded jointly by the federal and state governments.

Differences between Medicaid and Medicare

You should note that Medicare and Medicaid are different programs, both operated and funded by different parts of the government.

  • Medicaid is a federal and state program offering health coverage for those who earn significantly low incomes or otherwise qualify
  • Medicare is a federal program offering heal coverage for elderly citizens of more than 65 years old and those living with disabilities, regardless of their income
  • If you are eligible for both programs, you can have both as they will offer you health coverage and lower health costs.

Eligibility

Medicaid is the single largest source of health coverage in the US. It is a joint federal and state program that offers health coverage to millions of Americans, including seniors, pregnant women, children, parents, and people with disabilities. The federal law requires your state to cover certain groups of people in order to participate in the program.

Examples of mandatory eligibility groups in Medicaid include low-income families, people receiving Supplemental Security Income, qualified children, and qualified pregnant mothers. However, each state has additional options for this health coverage and can cover other groups that are not included in the mandatory eligibility groups. Some of the groups that may be covered include people who receive home and community-based services as well as children who are in foster care

Notably, the Affordable Care Act of 2010 gave states the power to expand the program in order to provide coverage to almost all low-income Americans who are under the age of 65. For instance, the eligibility of children was expanded to more than 133 percent of the FPL as most states cover children up to higher income levels. States are also allowed to expand the eligibility to adults who earn incomes of at most 133 percent of the federal poverty level. Accordingly, many states have chosen to extend Medicaid health coverage to adults. To know if your state has expanded the coverage for adults, and to what extent, feel free to contact The Mattar Firm today.

Services Covered by Medicaid

Medicaid covers the following services:

  • Physician services
  • Renal dialysis
  • Hospital care
  • Emergency dental services
  • Physical therapy
  • Alcoholism and substance abuse services
  • Special appliances and devices
  • Skilled nursing care
  • Short term, intermittent, home health services
  • Prosthetic devices
  • Chiropractic care
  • Hospice care
  • Medically necessary institutional group care
  • Psychiatric care
  • Medical equipment, supplies, and devices
  • Transportation for medical purposes
  • Nursing home care
  • Podiatric care (foot care) for diabetics
  • Optical (eye) services and supplies (with limits)
  • Prescription drugs (up to 4 prescriptions a month)
  • Miscellaneous medical services (which include laboratory and x-ray services, and family planning services and supplies)

Cost Sharing

Each state has an option of charging premiums and establishing out of pocket spending requirements for Medicaid enrollees. Some of the out of pocket costs include deductibles, copayments, and coinsurance among other similar charges. The maximum amount that you can pay towards these charges is limited; however, your state can apply higher fees for targeted groups of people who get relatively higher income.

It is worth noting that some vulnerable groups, such as pregnant mothers and children, are exempt from most of these out of pocket costs. They cannot also be charged for some services.

Premiums

Your state may charge limited enrollment and premiums fees on these groups of enrollees

  • Medically needy individuals
  • Disabled children who are eligible under the Family Opportunity Act (FOA)
  • Qualified disabled and working people with income above 150% of the federal poverty level
  • Disabled working people eligible under the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA)
  • Infants and pregnant women with family incomes of at least 150% of the FPL

States are allowed to charge higher, optional premiums on other groups if their family income is more than 150% of the FPL. Some vulnerable groups, such as children and institutionalized individuals, are exempted from these higher charges.

Prescription Drugs

Medicaid rules allow states to use the out of pocket charges in promoting the most cost-effective use of prescription drugs. In order to encourage using cost-effective drugs, your state can develop various co-payments for generic versus brand-name drugs, or it may do so for medicines that are on a preferred drug list. Notably, the cost-sharing for the non-preferred medicines for individuals who earn incomes of more than 150% of the federal poverty level can be as high as 20% of the actual cost of the drugs. However, copayments are limited to nominal amounts for individuals with incomes at or less than 150% of the FPL.

The law requires states to specify what drugs are considered preferred and non-preferred. Nonetheless, they have the power to establish different cost-sharing payments for mail order drugs as well as drugs that are sold in pharmacies.

Medically Needy

Each state has an option to develop a “medically needy program” for people who have significant health needs even if they have high income that otherwise makes them unqualified for the program.

Getting Started

Medicaid offers comprehensive health coverage and financial protection for tens of millions of Americans. Not everyone is eligible for Medicaid. If you or you know someone who wishes to know more about Medicaid, contact our non-crisis Medicaid planning lawyers at The Mattar Firm now.

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