What You Need To Know About Medicaid!

March 13, 2025

Medicaid is a federal and state-funded program that provides health insurance coverage to low-income individuals and families. It is designed to help people who might not otherwise be able to afford healthcare, including certain groups like children, pregnant women, seniors, and individuals with disabilities. Medicaid programs are managed by each state, so the specific benefits, eligibility requirements, and application process can vary depending on where you live.


Key Things You Need to Know About Medicaid:


Eligibility for Medicaid: Medicaid eligibility is typically based on factors such as income, household size, and specific circumstances. In general, eligibility is determined by:


    -  Income: Medicaid is designed for low-income individuals, and eligibility is often based on 

       the Federal Poverty Level (FPL). If your income is below a certain threshold, you may 

       qualify.

   -  Age and Health Status: Some groups are automatically eligible, such as:

      Children

      Pregnant women

      Seniors (65 or older)

      People with disabilities

   -  Family and Household Size: Medicaid eligibility also considers the size of your household 

      and your family members’ income.

   -  Expanded Medicaid: Under the Affordable Care Act (ACA), many states expanded 

      Medicaid to cover individuals with incomes up to 138% of the FPL. Some states have     

      opted not to expand Medicaid.


Benefits Covered by Medicaid: Medicaid provides a comprehensive range of health   

   services. While states are required to cover certain mandatory benefits, they also have the 

   option to cover additional optional benefits. Common services covered by Medicaid 

   include:

 

   - Doctor visits

   - Hospital services

   - Prescription drugs

   - Laboratory tests and X-rays

   - Emergency services

   - Mental health services

   - Rehabilitative services (like physical therapy)

   - Dental and vision care (in some states)

   - Maternity and newborn care

   - Home and community-based services (for people with disabilities or the elderly)

   - Preventive care: Vaccines, screenings, and wellness visits.


How Medicaid Works


   State-specific Programs: Medicaid is jointly funded by the federal government and states, 

   but each state administers its own program with different rules. This means coverage and 

   benefits can vary by state.


   Managed Care: In many states, Medicaid operates under a managed care system, where 

   beneficiaries get their care through private health plans that are contracted by the state.


   Fee-for-Service: Some states still operate Medicaid on a fee-for-service basis, where 

   providers are paid for each service they deliver.


How to Apply for Medicaid


Online or In-Person: You can apply for Medicaid online through your state’s Medicaid website, by phone, or in person at your local Medicaid office. Some states also have mobile apps to help with the application process.


Application Process: During the application process, you'll need to provide information about your income, household size, and any other relevant details (like disability or pregnancy status). The state will determine your eligibility and notify you whether you qualify for Medicaid or other assistance programs like CHIP (Children’s Health Insurance Program).


Special Enrollment Periods: Medicaid enrollment is open year-round, unlike other health insurance programs like those under the Affordable Care Act (ACA), which have open enrollment periods.


Medicaid for Children (CHIP)


Medicaid has a Children’s Health Insurance Program (CHIP) that provides coverage for children in families who earn too much to qualify for Medicaid but cannot afford private insurance. CHIP covers many of the same services as Medicaid and is available in every state.


Medicaid for Pregnant Women


In many states, pregnant women with low income can qualify for Medicaid, regardless of their immigration status. Medicaid helps cover prenatal care, labor, delivery, and postpartum care, including health services for the baby.


Income and Asset Limits


Medicaid uses both income and assets to determine eligibility. Each state may have different income and asset limits, and some states may allow a spend-down for people with income just above the threshold. This means you may be able to deduct certain medical expenses to qualify.


Medicaid and Medicare


If you're eligible for both Medicaid and Medicare (the federal health insurance program for those 65+ or with disabilities), you're considered dual-eligible. Medicaid can help cover costs that Medicare doesn't, such as premiums, co-pays, and certain services not covered by Medicare (like long-term care).


Cost and Coverage


No Premiums: Most Medicaid recipients don’t have to pay premiums for coverage, although some states may charge a small premium for certain services or individuals with higher incomes.


Out-of-pocket Costs: Depending on your state, you may be required to pay small copayments for services, but they are generally low compared to other insurance plans.


Additional Coverage: Medicaid often covers essential services that may not be available with private insurance, like long-term care (nursing homes or in-home care).


Medicaid for Long-Term Care


Medicaid is the largest payer of long-term care services in the U.S., including nursing home care and home-based services for elderly individuals or those with disabilities. However, qualifying for long-term care benefits typically requires individuals to meet certain asset and income limits.


Changing Medicaid Eligibility


Eligibility for Medicaid can change due to changes in income, family status, or health condition. It’s important to update your information with the Medicaid office if there are any significant changes. Some states have yearly renewal processes to ensure people still meet the eligibility criteria.


Important Considerations: 


Not All Providers Accept Medicaid: Some healthcare providers do not accept Medicaid, so it’s important to make sure your doctors or hospitals participate in the program.


State-Specific Variations: As Medicaid is run by each state, the benefits, eligibility, and application process can vary. Be sure to consult your state’s Medicaid website or office for specific details.


Sounds like a lot, right? Would you like to know more about Medicaid or how to apply? Contact Rhodes Law, P.A. at (321) 610-4542 and speak with Ruth C. Rhodes. She advises clients regarding how to qualify, obtain and maintain Medicaid benefits!


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