Understanding Medicaid

Signed into law in 1965, Medicaid and CHIP (Children’s Health Insurance Program) are joint federal-state programs designed to provide health insurance to low-income families and individuals. Though Medicaid began as a means of providing health coverage to government welfare recipients, it has grown to cover not only low-income citizens but certain sectors of the elderly and disabled populations. Today, approximately 72.5 million people receive benefits from Medicaid and CHIP annually, and at a cost of over $565.5 billion annually, it is one of the largest health insurance programs in the country.

With the passage of the Affordable Care Act (ACA), which stipulates looser eligibility standards, millions of people became newly eligible for Medicaid in the fall of 2013. Prior to the ACA, childless adults were largely excluded from this program. While the intention of the ACA was to cover nearly all U.S. citizens earning up to 138% of the federal poverty level, a Supreme Court ruling in 2012 made that expansion optional. As of January 2018, all but 18 states have chosen to implement the expansion.

As a consequence of the optional expansion of Medicaid, nearly 2.5 million adults fall into what has become known as the “coverage gap,” meaning they make too much to qualify for Medicaid, but not enough to qualify for Premium Tax Credit under the ACA. As of 2017, individuals who earn between 100% and 400% of the federal poverty level and meet other criteria can use this credit to help cover premiums for plans purchased through the ACA exchanges. Those who fall into the coverage gap may have little recourse other than to explore health care options for the uninsured.

Who is Eligible for Coverage?

Medicaid and CHIP eligibility is determined at the state level and is income-contingent, so each individual and family should check the Medicaid site to find their state’s policy. Childless adults between 18 and 65 are eligible for coverage in the 31 states enrolling in the ACA Medicaid expansion, but other states may not cover those individuals.

Medicaid Eligibility

Almost all adults living in states implementing the expansion qualify if they earn up to 138% of the FPL. Additionally, many children, pregnant women, parents, seniors and individuals with disabilities qualify for Medicaid, as long as they meet residency and immigration requirements and are documented U.S. citizens.

In states not implementing the expansion, qualification varies by state and income, as illustrated by the Kaiser Family Foundation.

CHIP Eligibility

CHIP provides coverage for uninsured children up to age 19 whose parents don’t qualify for Medicaid. State eligibility requirements vary, with the upper income limit for children’s families somewhere between 200% and 300% across the country.

CHIP also provides coverage to pregnant women, through CHIPRA, when they meet certain income eligibility limits but don’t qualify for Medicaid. Additionally, many states cover children and pregnant women who are not citizens but legally reside in the U.S. Finally, the ACA now provides states with the option to provide CHIP coverage to children of state employees, which was previously disallowed.

Understanding Your Benefits

Because Medicaid and CHIP are administered by states, benefits vary. However, there are minimum federal care standards to be provided to all Medicaid enrollees. People in states with expanded coverage will receive additional benefits.

Medicaid

All enrollees receive these mandatory benefits:

• Inpatient hospital services
• Outpatient hospital services
• EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
• Nursing Facility Services
• Home health services
• Physician services
• Rural health clinic services
• Federally qualified health center services
• Laboratory and X-ray services
• Family planning services
• Nurse Midwife services
• Certified Pediatric and Family Nurse Practitioner services
• Freestanding Birth Center services (when licensed or otherwise recognized by the state)
• Transportation to medical care
• Tobacco cessation counseling for pregnant women

Some states provide optional benefits:

• Prescription drugs
• Clinic services
• Physical therapy
• Occupational therapy
• Speech, hearing and language disorder services
• Respiratory care services
• Other diagnostic, screening, preventive and rehabilitative services
• Podiatry services
• Optometry services
• Dental services
• Dentures
• Prosthetics
• Eyeglasses
• Chiropractic services
• Other practitioner services
• Private duty nursing services
• Personal care
• Hospice
• Case management
• Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
• Services in an intermediate care facility for Individuals with Intellectual Disability
• State Plan Home and Community Based Service -1915(i)
• Self-Directed Personal Assistance Services- 1915(j)
• Community First Choice Option- 1915(k)
• TB Related Services
• Inpatient psychiatric services for individuals under 21
• Other services approved by the Secretary*
• Health Homes for Enrollees with Chronic Conditions- Section 1945

CHIP

Again, because states design their own CHIP programs, benefits can vary. All children enrolled in Medicaid receive comprehensive care services: Early and Periodic Screening, Diagnosis and Treatment (EPSDT). Those services include immunizations, sick doctor visits, regular checkups, vision and dental care, and others. All states enrolling in the CHIP Medicaid Expansion Program must provide EPSDT. However, states can design their own packages, as well; if they have a separate CHIP program, the state must provide dental coverage.

Optional CHIP benefits include:

• Benchmark coverage, based on:
  • The standard Blue Cross/Blue Shield preferred provider option service benefit plan offered to Federal employees
  • State employee’s coverage plan
  • The HMO plan that has the largest commercial, non-Medicaid enrollment within the state
• Benchmark-Equivalent coverage, which must be actuarially equivalent and include:
  • Inpatient and outpatient hospital services
  • Physician’s services
  • Surgical and medical services
  • Laboratory and x-ray services
  • Well-baby and well-child care, including immunizations
• Secretary-approved coverage, which includes any health coverage approved by the Secretary of the U.S. Department of Health and Human Services

Applying for Coverage

States often rely on health and community agencies to screen people for Medicaid and CHIP eligibility. To receive benefits, applicants must fill out a paper or online application and provide income and citizenship information. Children are allowed to start receiving Medicaid and CHIP services before their full application has been processed in states with presumptive eligibility rules.

Each state has its own means of enrolling individuals and families. While some are adopting the model Medicaid application provided through the ACA Marketplace, others rely on their own applications, which may look like this example from Nebraska. To enroll, an applicant must identify his or her state on the federal site and then navigate to the Medicaid/CHIP Application.

Seven states use Express Lane Eligibility to enroll applicants, meaning they glean information from approved agencies like the Supplemental Nutrition Assistance Program, School Lunch, and others in order to speed up the enrollment process.

For help enrolling in Medicaid, applicants can call local Medicaid eligibility offices, the state Department of Human Services office, or contact Aging and Disability Resource Centers. They can also use the following resources:

• InsureKidsNow: Resources to help applicants understand and apply for children’s Medicaid and CHIP benefits
• Consultants: There are numerous groups, such as Medicaid Consultants or Medicaid4You, that walk applicants through the process for a fee
• State resources: States like Maryland have put together enrollment guides

When applying, individuals and families need the following information:

• Certified birth certificates or other proof of citizenship/alien status for each individual applying for Medicaid/NCHC
• Identity documents for each individual applying for Medicaid/NCHC
• Social security cards, social security numbers, or proof that you have made an application for a number from the Social Security Office, for each individual applying for Medicaid or NCHC
• A copy of all pay stubs for last month
• Copies of all medical or life insurance policies
• A list of all cars, trucks, motorcycles, boats, or other large vehicles you or anyone in your household own, including the year, make, model, and vehicle identification number (VIN) for each
• Most recent bank statements
• A list of all real property you own
• Current financial statements/award letters from other sources of income, such as social security, retirement benefits, pensions, veteran benefits, and child support.

Finding a Provider

Once an individual or family is enrolled in the program, it’s critical that they find a doctor or hospital that accepts Medicaid. This can sometimes be difficult, depending on location. While city residents won’t usually have a problem, those who live in rural areas may need to do some searching.

Many states will have tools to find providers on their government Medicaid sites, such as this tool from Colorado. Other online resources can also be helpful:

• ZocDoc: This identifies providers accepting Medicaid across the country, including specialists
• Physician Compare: This is housed under the Medicare name, but also identifies physicians accepting Medicaid
• Hospital Compare: Similar to above, but listing hospitals

Conclusion

Medicaid is a state program, so it’s best to work directly with the state when determining eligibility and applying for the program. With expanded benefits coming to over half the states as a result of the ACA, many more individuals and families will receive health coverage.

To learn about individual state programs, use the following state-specific Medicaid sites: