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Medicaid Benefits and Eligibility

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Medicaid Benefits and Eligibility

The Medicaid program has become the single largest source of health insurance provider within the U.S., offering coverage to over 72.5 million citizens. Often coupled with the Children’s Health Insurance Program (CHIP), these initiatives are largely aimed at low-income households with children. Like CHIP, Medicaid coverage is determined by the federal government and state. However, certain important aspects of these programs differ, including eligibility requirements.

For those wondering “What is Medicaid designed to cover?” the government has established a number of benefits that must be included in each plan. However, each individual state has the ability to decide whether or not to include other “optional” coverage benefits, such as vision and dental care. If interested in Medicaid enrollment, it is important to understand the qualifications needed to receive benefits, what the program includes and how to apply for coverage.

What is Medicaid?

Medicaid is a joint federal and state health insurance program. Throughout the U.S., Medicaid coverage is available to low income households that meet certain qualifications. Federal law requires states to offer coverage to certain groups of individuals, including low income families, pregnant women, children and disabled individuals. Additionally, the Affordable Care Act of 2010 allowed states to expand coverage to nearly all low income Americans, should the state choose to do so.

Medicaid enrollment is handled on a state level, so applications are accepted at local offices. As such, the process to initially apply or appeal a denial may vary depending on where each applicant resides.

Who qualifies for Medicaid?

Several Medicaid qualifications must be met in order for applicants to receive coverage. The first requirement that must be met concerns citizenship and lawful presence. In order to receive benefits, an applicant must either be a U.S. citizen or a qualifying non-citizen, such as a lawful permanent resident. Additionally, applicants can only apply for the state Medicaid program for the state they live in.

Medicaid income limits are determined by household size and the federal poverty level. In most cases, the modified adjusted gross income (MAGI) is utilized to determine financial eligibility for the program. MAGI takes a number of factors into consideration when determining eligibility, including taxable income. These limits often vary between states, and not every eligibility group is required to meet MAGI income guidelines in order to receive coverage. In some cases, coverage may be based upon participation in another federal or state program.

When it comes to non-financial Medicaid eligibility requirements, it is important to understand that each state has the ability to enforce additional requirements. In some states, eligibility groups are limited by age, pregnancy or parenting status. For example, some states do not provide coverage to adults under the age of 65 who do not have any dependents.

When can I apply for Medicaid?

There is no Medicaid open enrollment, unlike traditional health insurance programs. You can apply for this form of health insurance at any time. If you are qualified, you can begin to receive coverage as soon as your application is approved. In some cases, coverage may even be retroactive up to three months prior to the application date, so long as you were eligible during that time.

How to Apply for Medicaid

You can submit a Medicaid application at a local office. Acceptable application methods vary by state. However, you may be eligible to apply online, by mail or in person. When applying online, you can submit an application directly with your local agency’s website, if your state allows. Otherwise, you can apply through the online Healthcare Marketplace.

When considering “What do you need to apply for Medicaid?” there are several items to keep in mind. Your application will ask you to provide a number of documents in order to determine your eligibility for the program. It is crucial that you provide your local office with any required documents as soon as possible in order to avoid a delay in benefits or an application denial. When applying for Medicaid coverage, you may be asked to provide documentation such as:

  • Proof of age.
  • Proof of citizenship or a lawful non-citizen status.
  • Proof of income.
  • Proof of your disability, if you may qualify due to a disability.
  • Proof of your address.
  • Proof of any other type of health insurance that you may have, such as Medicare.

What does Medicaid cover?

As stated previously, Medicaid coverage varies by state. However, there are some forms of coverage that are mandatory for all state versions of the program. This includes:

  • Inpatient and outpatient hospital services.
  • Preventative care.
  • Nursing facility and home health services.
  • Lab work and x-rays.
  • Family planning and nurse midwife services.
  • Certified pediatric and family nurse practitioner services.
  • Transportation to medical care.

Optional Medicaid coverage is determined on a state-by-state basis. These include, but are not limited to prescription drug coverage, dental services and occupational therapy. Some optional services may only be available to certain age groups, or those with certain conditions. For example, some states provide Medicaid dental coverage to children who are under the age of 18, or emergency services to adults 18 years of age and older.

How much does Medicaid cost?

Medicaid costs may vary depending on the state that you reside in, and your income level. The program allows for states to charge premiums and establish out-of-pocket spending requirements for qualifying beneficiaries, also known as cost-sharing. In states that do require a premium or cost-sharing, this amount is generally determined by your income level. In other states, coverage is offered without any fees to the beneficiary.

Do I have to reapply for Medicaid every year?

A Medicaid renewal must generally take place each year in order to determine whether or not you are still eligible for coverage. Depending on the state that you reside in, you may have the opportunity to renew online, by mail or at your local office. Some states allow you to opt for an auto-renewal, where your local office will determine your eligibility automatically without requiring additional information. For financial eligibility, this is generally done by verifying your income using the latest year’s tax return information.

How to Appeal a Medicaid Claim Denial

If you are denied Medicaid or if you are denied coverage for a particular service that you believe should have been covered, you will be provided with a determination notice that includes instructions on the appeal process within your state. If you wish to submit an appeal, you will need to do so within the set period of time that is indicated on your notice. Failure to appeal within that time period, results in a dismissal of your appeal.