Alyssa Lane
Medicaid is a joint federal and state program that provides free or low-cost health coverage to Americans with limited incomes and resources. This includes children, adults, pregnant women, people with disabilities, and seniors. The eligibility criteria and benefits covered under Medicaid vary by state, and some states have expanded their programs to cover all individuals below certain income levels. Individuals can apply for or re-enroll in Medicaid at any time of the year, and there are resources available to help determine eligibility and understand the specific program in each state, such as the Ohio Medicaid Consumer Hotline and the New York State Medicaid News page.
| Characteristics | Values |
|---|---|
| Coverage | Free or low-cost health coverage |
| Who is it for? | Low-income people, families and children, pregnant women, the elderly, and people with disabilities |
| Application | Apply or re-enroll any time of year |
| Expansion | Some states expanded their programs to cover all people below certain income levels |
| Medicare vs Medicaid | Medicare is for over 65s and some under 65s with certain disabilities or conditions. Medicaid is for those with limited income and resources |
| Ambulance services | Covers emergency ambulance services when provided by licensed providers |
| Dental services | Federal law requires states to cover dental services for people under 21. States can choose whether to provide benefits to people 21 and older |
| State-specific programs | Some states have specific programs, e.g. New York State Medicaid, Ohio Medicaid |
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What You'll Learn
Who is eligible for Medicaid?
Eligibility for Medicaid is based on income and family size. Eligibility rules differ among states, and some states have expanded their Medicaid programs to cover adults with low incomes. In all states, Medicaid gives health coverage to some individuals and families, including children, parents, pregnant women, elderly people with certain incomes, and people with disabilities.
Medicaid eligibility for individuals 65 and older or who have a disability or blindness is generally determined using the income methodologies of the SSI program administered by the Social Security Administration. Some states use more restrictive eligibility criteria than SSI but still largely apply SSI methodologies. Eligibility for the Medicare Savings Programs, through which Medicaid pays Medicare premiums, deductibles, and/or coinsurance costs for beneficiaries eligible for both programs, is determined using SSI methodologies.
Certain Medicaid eligibility groups do not require a determination of income by the Medicaid agency. This coverage may be based on enrollment in another program, such as SSI or the breast and cervical cancer treatment and prevention program. Children with an adoption assistance agreement in effect under title IV-E of the Social Security Act are automatically eligible, as are young adults who meet the requirements for eligibility as former foster care recipients. To be eligible for Medicaid, individuals must also meet certain non-financial eligibility criteria. Medicaid beneficiaries must be residents of the state in which they are receiving Medicaid and must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.
States have the option to establish a "medically needy program" for individuals with significant health needs whose income is too high to otherwise qualify for Medicaid under other eligibility groups. Medically needy individuals can still become eligible by "spending down" the amount of income that is above a state's medically needy income standard. Individuals spend down by incurring expenses for medical and remedial care for which they do not have health insurance.
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Medicaid and Medicare
Medicare and Medicaid are two separate, government-run programs that help cover health care costs for certain American residents. They are operated and funded by different parts of the government and primarily serve different groups.
Medicare is a federal program that provides health coverage for people aged 65 and older and those with a disability. The Social Security Administration (SSA) determines eligibility for Social Security Disability Insurance benefits (SSDI) based on whether the applicant can work. Medicare has four parts that each cover different things: hospitalization, medically necessary services, supplemental coverage, and prescription drugs. Most people don't pay a premium for Part A, but deductibles and coinsurance apply. Those eligible for Medicare Part A also qualify for Part B, which covers medically necessary services and equipment. Medicare Part D provides prescription drug coverage, for which participants pay out of pocket. Medicare is available to nearly every American aged 65 and over.
Medicaid is a joint federal and state program that helps cover medical costs for people with limited income and resources, including low-income families and children, pregnant women, the elderly, and people with disabilities. The eligibility requirements and benefits can vary from state to state, and each state runs its own program. While Medicaid has strict eligibility requirements, they are different in each state, and some states allow individuals to "spend down" their income to qualify. Medicaid offers benefits that Medicare doesn’t normally cover, like nursing home care, personal care services, prescription drugs, eyeglasses, and hearing aids. People with Medicaid usually don’t pay anything for covered medical expenses but may owe a small co-payment for some items or services.
Individuals who are enrolled in both Medicaid and Medicare, by federal statute, can be covered for both optional and mandatory categories. In total, 12 million people are "dually eligible" and enrolled in both programs, composing more than 15% of all Medicaid enrollees. If you are dually eligible, Medicare covers your prescription drugs, and Medicaid may pay for other drugs and services that Medicare doesn't cover.
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Medicaid and dental services
Dental health is an important part of people's overall health. While Medicaid programs are required to cover dental services for children and youth under the age of 21, states choose whether to provide dental benefits for adults.
Dental Services Covered by Medicaid for Children
Dental services for children must minimally include oral screening, dental examinations, and treatment of suspected illness or conditions. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). A referral to a dentist is required for every child in accordance with the periodicity schedule set by a state.
Dental Services Covered by Medicaid for Adults
States have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees. There are no minimum requirements for adult dental coverage. While most states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care.
Improving Access to Dental Services for Medicaid Enrollees
The Centers for Medicare & Medicaid Services (CMS) is committed to improving access to dental and oral health services for beneficiaries enrolled in Medicaid and CHIP. In 2010, CMS established an Oral Health Initiative (OHI) to improve children's access to appropriate preventive dental care. Since the OHI was established, there have been increases in Medicaid and CHIP enrollment among children and adults, as well as state expansion of dental benefits.
Dental Services Covered by MassHealth
MassHealth members enrolled in certain programs can receive coverage for dental care, including preventive and restorative services like routine cleanings, plaque or stain removal, topical fluoride treatments, sealants, and fillings. MassHealth will only pay for covered dental services if they are provided by dental providers in their provider network.
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Applying for Medicaid
Medicaid provides free or low-cost health coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly, and people with disabilities. The Children's Health Insurance Program (CHIP) is also available and covers children and teens up to the age of 19.
To apply for Medicaid, you must first create an account with the Health Insurance Marketplace. You can then fill out an application form. If it looks like anyone in your household qualifies for Medicaid, your information will be sent to your state agency, who will contact you about enrollment. You can apply for or re-enroll in Medicaid at any time of year.
If your state agency deems someone in your household ineligible, you will receive a notice explaining this. In most cases, the state will securely send your information to the Marketplace, and you will receive a letter about applying for Marketplace coverage. You can apply for Marketplace coverage by logging into your Marketplace account. Your application will be pre-filled with the information you gave to the state agency.
If your income is too high for Medicaid, you may still qualify for savings on a Marketplace insurance plan. Your state may not have expanded Medicaid, which may limit your coverage options. Depending on your income, you may not qualify for savings on a private insurance plan. However, even if you don't qualify for Medicaid based on income, you should still apply, especially if you have children, are pregnant, or have a disability.
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Medicaid and CHIP
Medicaid is a federal program that provides free or low-cost health coverage to people with low incomes. The program covers children, pregnant women, the elderly, and people with disabilities. Each state has its own eligibility requirements, which may consider income, household size, family status, disability, age, and other factors. For example, in Texas, a child might be eligible for Children's Medicaid if their family's monthly income is the same or less than the limit listed.
Medicaid programs must follow federal guidelines, but coverage and costs vary from state to state. Some states expanded their Medicaid programs to cover all people below certain income levels, while others use private insurance companies to provide coverage. It is important to note that not every provider accepts Medicaid, so finding a Medicaid-accepting healthcare provider may require checking with the state's Medicaid agency. Additionally, Medicaid may help pay for medical care received up to three months before enrollment.
The Children's Health Insurance Program (CHIP) is a related program that provides health coverage to eligible children through both Medicaid and separate CHIP programs. CHIP is designed for children in families with incomes too high to qualify for Medicaid but too low to afford private coverage. CHIP provides low-cost health coverage, and in some states, it also covers pregnant individuals. CHIP qualifications vary by state and depend primarily on income. Enrollment fees and co-pays for CHIP are typically based on family income, with lower fees for lower-income families.
To apply for Medicaid or CHIP, individuals should check their eligibility and apply through their state's Medicaid agency or the Health Insurance Marketplace. Applications can be submitted at any time during the year, and enrollment is handled by the state agency. Even if someone does not qualify for Medicaid based on income, they are encouraged to apply, as they may still be eligible for their state's program, especially if they have children, are pregnant, or have a disability.
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Frequently asked questions
Medicaid is a joint federal and state program that provides free or low-cost health coverage to Americans with limited income and resources.
Eligibility for Medicaid is based on income and resources. Medicaid is available to children, adults, pregnant women, people with disabilities, and seniors.
You can check your eligibility for Medicaid by entering your household size and state. If you have limited Medicaid coverage, you can fill out an application through the Marketplace to see if you qualify for full-benefit coverage.
Medicaid covers Emergency Ambulance services provided by licensed providers and inspected, permitted vehicles. Federal law also requires states to cover dental services for people with Medicaid under the age of 21.
You can apply for or re-enroll in Medicaid at any time of year through the official website.
