Medicaid Eligibility & The Legal Scope of Coverage
While the federal government funds the Medicaid program, each state manages it independently. It is meant to cover healthcare costs for people who have very limited income and assets. If you receive Supplemental Security Income (SSI), you probably will qualify for Medicaid automatically. You must be a U.S. citizen or a lawful permanent resident, unless you are seeking treatment for an emergency medical condition or a pregnancy. (Non-emergency prenatal care also may be covered for women without citizenship or a green card.)
Categories of Medicaid Eligibility
In addition to meeting financial eligibility requirements, an applicant will need to fit into one of certain specific categories. These include being over 65, having a disability, or going through a pregnancy, as well as having breast or cervical cancer. The healthcare costs of children born to mothers who are on Medicaid will be covered for one year after their birth. Some states have extended Medicaid coverage to low-income people with children or people under 65 who have an income no greater than 133 percent of the federal poverty level. The financial eligibility threshold varies depending on the reason for seeking Medicaid benefits.
Most states also offer Medicaid coverage to people who technically are not eligible for Medicaid but are facing massive medical costs. These costs would need to reach a level at which they deplete the individual’s income and assets so greatly that their remaining income and assets make them eligible.
If your household does not qualify for Medicaid but cannot afford private insurance, you may be able to cover your children’s medical expenses through the Children’s Health Insurance Program in your state.
The Scope of Medicaid Coverage
The services covered by Medicaid vary from state to state. However, each state must cover both inpatient and outpatient hospital treatment, prescriptions, the fees for lab testing, transportation costs related to medical care, the costs of long-term care, and the costs of vision and dental care for children. Some additional services that states often provide include physical therapy, prescription glasses, hearing aids, treatment for mental health conditions, and hospice care. Not every healthcare provider accepts Medicaid, so actually receiving a service can pose an additional logistical challenge.
You must prove that the service is medically necessary to get coverage through Medicaid. Definitions of what a medical necessity means vary from state to state. The main idea is that you cannot ask Medicaid to cover optional medical procedures.
Sometimes the state will pay the cost of the medical services directly, which is known as “fee for service” Medicaid. In other situations, you may receive services through a managed care organization. A state may retain this type of medical provider specifically to provide services that are covered by Medicaid. The difference between these alternatives usually does not have an impact on the consumer, who will need to pay little or nothing for the services either way.
Applying for Medicaid
You can apply for Medicaid coverage directly through the Medicaid agency in your state. If your application is denied, you can review the basis for the denial in the written notice that you will receive and determine whether you want to file an appeal.
