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Medicaid Health Insurance

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About Medicaid Health Plans

Medicaid health plans provide better care coordination for beneficiaries, providing beneficiaries with continuity—and lower costs—through a dedicated provider that can coordinate care. Medicaid health plans are also working with expectant mothers to provide prenatal care and counseling to help them transition to caring for newborns. Medicaid health plans include programs to coordinate care for beneficiaries with multiple chronic conditions, outreach and education initiatives to promote prevention and healthy living, and efforts to facilitate beneficiaries’ access to non-medical support, such as social services or transportation.

What is Medicaid?

Medicaid is a federal government program to help provide healthcare coverage to certain groups of people who have low income and few assets (other than the home they live in). Among those covered by Medicaid are people over 65 and those with disabilities. Each state runs its own version of Medicaid, with slightly different rules and coverage.

The Affordable Care Act, signed by President Obama on March 23, 2010, creates a national Medicaid minimum eligibility level of 133% of the federal poverty level ($29,700 for a family of four in 2011) for nearly all Americans under age 65. California is expanding its Medicaid program to cover households with incomes up to 138% of the federal poverty level. That works out to $16,105 a year for 1 person or $32,913 for a family of 4.

What Does Medicaid Cover?

Although the States are the final deciders of what their Medicaid plans provide, there are some mandatory federal requirements that must be met by the States in order to receive federal matching funds. Required services include:

  • 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
  • Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21

Who Pays for Health Services Provided by Medicaid?

Medicaid does not pay money to individuals but operates in a program that sends payments to the health care providers. States make these payments based on a fee-for-service agreement or through prepayment arrangements such as health maintenance organizations (HMOs).

Each State is then reimbursed for a share of their Medicaid expenditures from the Federal government.

States may require small deductibles, coinsurance, or copayments on some Medicaid beneficiaries for certain services. However, the following Medicaid beneficiaries must be excluded from cost-sharing:

  • Pregnant women,
  • Children under age 18, and
  • Hospital or nursing home patients who are expected to contribute most of their income to institutional care.

Who’s Eligible for Medicaid?

Each state sets its own Medicaid eligibility guidelines. The program is geared towards people with low incomes, but eligibility also depends on meeting other requirements based on age, pregnancy status, disability status, other assets, and citizenship.

States must provide Medicaid services for individuals who fall under certain categories of need in order for the state to receive federal matching funds. For example, it is required to provide coverage to certain individuals who receive federally assisted income-maintenance payments and similar groups who do not receive cash payments. Other groups that the federal government considers “categorically needy” and who must be eligible for Medicaid include:

  • Individuals who meet the requirements for the Aid to Families with Dependent Children (AFDC) program that were in effect in their state on July 16, 1996
  • Children under age 6 whose family income is at or below 133% of the Federal poverty level (FPL)
  • Pregnant women with family income below 133% of the FPL
  • Supplemental Security Income (SSI) recipients
  • Recipients of adoption or foster care assistance under Title IV of the Social Security Act
  • Special protected groups, such as individuals who lose cash assistance due to earnings from work or from increased Social Security benefits
  • Children born after September 30, 1983 who are under age 19 and in families with incomes at or below the FPL
  • Certain Medicare beneficiaries

What is Dual Eligibility?

Individuals who are eligible for both Medicaid and Medicare.

What Are the Benefits of Medicaid?

Medicaid medical coverage includes the most common forms of healthcare, Medicaid medical benefits cover at least the same healthcare services that Medicare does, as well as some services that Medicare doesn’t cover. Medicaid also pays Medicare premiums, deductibles, and co-payments for people who are enrolled in both programs. Medicaid is not free health insurance—states have the option to charge premiums and to establish out of pocket spending (cost-sharing) requirements for Medicaid enrollees.

Don’t confuse Medicare with Obamacare insurance or Medicaid insurance. Basically, traditional Medicare is health insurance provided by the government. Obamacare is health insurance that you buy from an insurance company, or get from your employer. Medicaid is a government healthcare subsidy that offers free or low-cost care for those who qualify based on income and family size.

How Do I Apply for Medicaid?

Fill out an application in the Health Insurance Marketplace. When you finish the application, you’ll be told which programs you and your family qualify for.