Medicaid is a health insurance coverage program for people of all ages who’s assets, income and resources are insufficient to afford private health insurance. Medicaid is the largest source of funding for medical and health-related services in the United States and is jointly funded by the individual state and the federal government, however the program within each state is managed by the state itself. Each of the fifty United States have a Medicaid program, though they are not required to have a Medicaid program. Recipients of Medicaid must be a United States citizen or legal permanent resident and may include low-income adults and their children along with people suffering from certain types of disabilities, however poverty alone does not qualify a person for Medicaid.

Each state is free to design their own reimbursement and delivery system under the Medicaid Program. The Social Security Act allows flexibility in Medicaid operation by states by authorizing multiple waivers. This program offers coverage for Long Term Care Services including Institutional Care and Home and Community Based Services. Some states run Medicaid and the Children’s Health Insurance Program (CHIP) as a single combined program.

The goal of Medicaid is to provide safe, effective, efficient and quality care, which is equitable and patient-oriented.

Eligibility for Medicaid

Medicaid and CHIP together cover around 60 million Americans including children, pregnant women, parents, seniors and disabled people. Each state has its own eligibility criteria. Federal law requires States to cover certain mandatory eligibility groups, they are also free to cover optional eligibility groups. Most people under age 65 having individual incomes up to about $15,000 per year will qualify for Medicaid in every state by beginning of 2014.

Some common eligibility criteria for Medicaid are:

  • Disabled people are eligible for Medicaid in every state. Some states include them automatically if they get Supplemental Security Income (SSI) benefits. In other state they are included on basis of income and resources.
  • The Affordable Care Act expands help to low-income adults with disabilities failing to meet disability requirements of the SSI program. It will also include people under age 65, including people with disabilities, with income of about $15,000 yearly.
  • Some states allow people with disabilities above regular income limit to enroll in Medicaid through “buy-in” programs.
  • The child born of Medicaid covered parent(s) will automatically have Medicaid coverage until they are one year old.
  • Coverage for children is offered through Medicaid and CHIP in all 50 states. In a family of four. Children are eligible for Medicaid if the family’s yearly income does not exceed $45,000.
  • Pregnant women are eligible for Medicaid coverage including their unborn and infant if they fall under limited income group i.e. about $20,000 as an individual. This may vary from state to state.
  • Women with breast or cervical cancer are also eligible for Medicaid through Breast and Cervical Cancer Prevention and Treatment (BCCPT) Medicaid programs. 

Benefits of Medicaid

States are free to design their own Medicaid programs including the type, amount, duration, and scope of services. But they have to provide coverage for certain “mandatory benefits,” and are free to offer other “optional benefits” such as prescription drugs.

The mandatory benefits under Medicaid are:

  • Laboratory and X-ray services
  • Inpatient and Outpatient Hospital services
  • Health screenings for children
  • Treatment for children in case of any medical problem
  • Comprehensive dental services for children
  • Comprehensive vision services for children
  • Family planning services and related medical supplies
  • Long-term care services and supports
  • Medical and surgical dental services for adults
  • Pediatric and family nurse practitioner services
  • Health clinic services
  • Nurse-midwife services
  • Nursing services for adults
  • Home health care services (only in select cases)

Some optional benefits under Medicaid are:

  • Prescription drugs
  • Physical and occupational therapies
  • Speech therapy
  • Visit to doctor for vision care and eyeglasses
  • Audiology, ear care and hearing aids
  • Prosthetic devices
  • Mental health services
  • In-home long-term care
  • Case management
  • Personal care services
  • Hospice services
  • Community-based care

Cost of Medicaid

States can charge premiums or offer Medicaid on cost sharing basis. Cost sharing may include copayments, coinsurance, deductibles or other charges. Cost sharing for Medicaid may vary from state to state. The goal is to make Medicaid – and thereby medical care – affordable for those enrolled, yet not free to everyone.

The Future of Medicaid

Under the Patient Protection and Affordable Care Act, Medicaid will significantly expand both federal funding and eligibility beginning January 1, 2014.  Under the new law, as it was written, any legal resident of the United States with an income of up to 133% of the federal poverty line would qualify for coverage in any state which participates in the Medicaid program – this includes adults who do not have dependent children. However, the U.S. Supreme Court ruled that states do not have to agree to this expansion in order to receive existing levels of funding, many states have chosen to continue with the current funding levels and eligibility standards as opposed to adopting the new standards that would go into effect January 1, 2014.