Paul Sanchez
Medicaid is a federal program that provides free or low-cost medical benefits to people with low incomes. Since Medicaid is administered at the state level, many states refer to their Medicaid programs by alternative names. For example, in Virginia, Medicaid members can choose from various health plans, including FAMIS and FAMIS MOMS. Each state has its own requirements for Medicaid eligibility, and most states also have their own Children's Health Insurance Program (CHIP) with different qualifications.
| Characteristics | Values |
|---|---|
| Type | Health insurance |
| Target Group | Low-income people, including families, children, pregnant women, elderly adults, and people with disabilities |
| Cost | Free or low-cost |
| Coverage | Nursing home care, personal care services, nursing facility services, home health services, and assistance with Medicare premiums |
| Administered By | States, according to federal requirements |
| Funding | Jointly funded by states and the federal government |
| Alternative Names | State Plan, Title XIX, Children's Health Insurance Program (CHIP) |
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What You'll Learn
Children's Health Insurance Program (CHIP)
The Children's Health Insurance Program (CHIP) provides health coverage to children in families with incomes too high to qualify for Medicaid but too low to afford private coverage. CHIP is managed by states according to federal requirements and funded by both state and federal sources. Each state has its own rules about who qualifies for CHIP, and the benefits provided vary by state. However, all states provide comprehensive coverage, including routine "well child" doctor and dental visits, and no family will pay more than 5% of their annual income for CHIP coverage.
CHIP is available in all states, and each state works closely with its state Medicaid program. CHIP benefits are different in each state, but all states provide comprehensive coverage. Some states, for example, provide free routine "well child" doctor and dental visits under CHIP. There may also be a fixed amount, such as $20, that enrollees pay for a covered health care service after paying their deductible.
You can apply for CHIP at any time of year, and there is no limited enrollment period. If you qualify, your coverage can start immediately. To apply, you can submit a Marketplace application, which will also allow you to find out if you qualify for an individual insurance plan with savings based on your income. You can also apply for Medicaid coverage through your state agency, which will inform you if your children qualify for CHIP. If they do, you won't need to buy a separate insurance plan to cover them.
In some states, CHIP covers pregnant women as well. It is important to note that if your children are eligible for CHIP, they won't be eligible for any savings on Marketplace insurance. However, CHIP coverage will likely be more affordable.
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State Plan
The State Plan is a formal, written agreement between a state and the federal government, describing how a state administers its Medicaid program. The State Plan is a contract developed by the state and approved by the Centers for Medicare and Medicaid Services (CMS), operating under the authority delegated by the Secretary of the U.S. Department of Health and Human Services (HHS). The state plan outlines the nature and scope of the Medicaid program in each state, including the groups of individuals covered, the services provided, and the reimbursement methodologies for providers. It also specifies the state-specific standards for eligibility, methodologies for provider reimbursement, and processes for administering the program.
The State Plan is a comprehensive document that must be approved by the CMS for the state to access federal Medicaid funds. States make operational and policy decisions that determine eligibility, covered services, and payment settings. The plan can be amended as necessary to reflect changes in state policy and federal law and regulations. States submit State Plan Amendments (SPAs) to request permissible program changes, make corrections, or update their Medicaid or Children's Health Insurance Program (CHIP) state plan with new information.
The first page of the State Plan requires the state to acknowledge that, to receive federal funds under Title XIX of the Social Security Act, the single state agency must agree to administer the program in accordance with the requirements of Titles XI and XIX and all applicable federal regulations. While the state plan is related to specific federal statutes and regulations, not all federal rules regarding the Medicaid program are included in it. CMS uses additional mechanisms, such as state systems advance planning documents, to record how states implement federal Medicaid requirements.
The State Plan document is organized into seven sections, with each page generally referencing a specific federal provision or group of related provisions. Submission of the page is considered the state's agreement and assurance of compliance with the provision. If new federal Medicaid statutes, rules, or court decisions are made, CMS must develop a new state plan amendment template for states to complete and submit for review. This process allows CMS to determine whether the plan continues to meet federal requirements and authorize federal expenditures for new eligibility groups or services.
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Title XIX
Each state designates a Medicaid agency responsible for developing and submitting a State Plan, which outlines how the state will administer its Medicaid programs. The State Plan includes a list of groups of individuals to be covered, the healthcare services to be provided, methods for paying providers, provider qualifications, and the administrative activities necessary to carry out the program. States send State Plan Amendments (SPAs) to the Centers for Medicare and Medicaid Services (CMS) for review and approval. SPAs are also used to request program changes, make corrections, or update plans with new information.
Certain groups of people are automatically eligible for Medicaid, including children, the elderly, blind, and/or disabled people, and those eligible to receive federally-assisted income maintenance payments. States can also establish a "medically needy program" for individuals with significant health needs whose income is too high to qualify for Medicaid under other eligibility groups.
Over the years, the Medicaid program has been modified to better meet the needs of low-income individuals. For example, the Social Security Amendments of 1967 added the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which provides children under 21 enrolled in Medicaid with age-appropriate screening, preventive services, and treatment for identified conditions. In 1993, the Omnibus Budget Reconciliation Act (OBRA) gave states permission to create Drug Utilization Review ("DUR") boards to manage state-specific drug purchasing and formulary decisions for state-purchased care under the Medicaid program.
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Nursing home care
Medicaid is a joint federal and state program that helps cover health care costs for people with limited incomes, resources, or financial means. It serves eligible older adults, younger adults, children, expectant mothers, and people with disabilities. While Medicaid programs vary from state to state, it generally provides 100% coverage for nursing home care for eligible beneficiaries.
To qualify for Medicaid-covered nursing home care, individuals must meet specific criteria. Firstly, they must meet the Nursing Home Level of Care (NHLOC) criteria, which vary by state. This assessment evaluates factors such as physical functional ability, cognitive functioning, medical needs, and behavioural issues to determine if an individual requires the level of care provided in a nursing home. Secondly, there are financial criteria to consider. Individuals must meet certain income and asset limits to be eligible for Medicaid nursing home coverage. These limits differ across states, so it is essential to check the specific requirements in your state.
Medicaid-certified nursing homes provide three main types of services: skilled nursing or medical care, rehabilitation services, and long-term care. These services aim to promote the highest practicable physical, mental, and psychosocial well-being of each resident. It is important to note that not all nursing homes accept Medicaid, so individuals should verify that their chosen facility is a Medicaid-certified nursing facility. Additionally, Medicaid coverage for nursing home care is typically available when there are no other payment options, and individuals must explore other long-term care options to transition back to the community as quickly as possible.
While Medicaid and Medicare are both health insurance programs, they serve different purposes. Medicaid focuses on providing long-term care and personal care services, including nursing home care. On the other hand, Medicare is a federal program primarily covering medical services for older adults and individuals with specific disabilities. Some individuals may qualify for both programs, and it is important to understand the differences in coverage and eligibility requirements between the two.
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Personal care services
Medicaid is a state-level program, and as such, its administration and nomenclature vary across the different states. Some states refer to their Medicaid programs by alternative names, such as the State Plan or Title XIX.
To qualify for PCS, an individual must have a medical condition, disability, or cognitive impairment and demonstrate unmet needs for assistance with ADLs. The specific criteria for qualifying for PCS vary slightly depending on the state. For instance, in Texas, individuals must be aged 20 or younger, have an ongoing disability or mental illness confirmed by a doctor or practitioner, and need assistance with ADLs and IADLs. In North Carolina, individuals must demonstrate unmet needs for three out of five ADLs with limited hands-on assistance, two ADLs with one requiring extensive assistance, or two ADLs with one requiring full dependence on another person.
PCS program eligibility is determined by an independent assessment conducted by the state's Medicaid program or its designee. The assessment takes into account the individual's specific needs and results in an individualized service plan. The frequency and duration of PCS provided are determined by the beneficiary's PA (Prior Authorization) approved daily units, calculated using the available PA information at the time of adjudication.
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Frequently asked questions
Since Medicaid is administered at the state level, many states refer to their Medicaid programs by alternative names. Some of the different insurance names for Medicaid include:
- State Plan
- Title XIX
- FAMIS
- CHIP (Children's Health Insurance Program)
FAMIS is a health plan available to members enrolled in Medicaid in Virginia. FAMIS members can choose their health plan when they apply, and will receive a Commonwealth of Virginia insurance card from the Department of Medical Assistance Services (DMAS).
CHIP, or the Children's Health Insurance Program, covers medical and dental care for uninsured children and teens up to age 19. CHIP qualifications vary by state, but generally depend on income.
To apply for Medicaid, you must be a resident of the state where you are applying for benefits. You can create an account with the Health Insurance Marketplace and fill out an application. If it looks like you qualify for Medicaid, your information will be sent to your state agency, which will contact you about enrollment.
