Understanding Government Sponsored Health Insurance Center for Medicare and Medicaid Services: Medicaid

What is Medicaid?

Medicaid is a government program that provides health coverage for some low-income people and families. Each state runs its own Medicaid program. Within federal guidelines, states decide what Medicaid will cover and who will be eligible. Check this list of state agencies which administer Medicaid.

For more general information and Medicaid, contact the Center for Medicare and Medicaid Services.

How do I get Medicaid?

To qualify for Medicaid, you must meet three key requirements.

First, you must fit into one of Medicaid's four eligibility categories. You must be:

• a child
• the parent of a dependent child
• disabled, or
• elderly

Generally, adults who are not parents, disabled, or elderly cannot be covered by Medicaid. However, twenty states have opened up Medicaid, or created a separate health coverage program, for such adults. These states are Arizona, Arkansas, Connecticut, Delaware, Hawaii, Illinois, Maine, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, New York, Oklahoma, Oregon, Pennsylvania, Utah, Vermont, Washington, and Wisconsin. Check with your state Medicaid department for more information.

Second, states set income eligibility limits for each of these categories. Your income (and, often, your assets, or savings) must be below these limits in order to qualify for Medicaid.  For children, income limits tend to be higher. For adults, however, most states set very low income limits, well below the federal poverty level (in 2008, the federal poverty level was $10,400 a year for a single person and $17,600 for a family of three.)

In many states, if you have very high medical or pharmacy expenses each month and you fit into a Medicaid eligibility category, but your income is too high for that category, you still might be eligible. Some states will subtract your medical expenses from your income until you reach the income eligibility limit. This is called "spend down" and it can help some people qualify for Medicaid after they have paid for a portion of their medical expenses.

Third, you must be a US citizen or, if you are not a citizen, you must have been legally residing in the US for at least five years. Recent immigrants and non-citizens without immigration documents cannot enroll in Medicaid.

To get an idea if you might be eligible for Medicaid coverage, go to Benefitscheckup.org. Click on "Find Benefits" then click on the "comprehensive" option. This Web site is sponsored by the National Council on Aging, a non-profit group.

At the site, you can also find a list of state Medicaid program Web sites. Information on these sites will explain more about Medicaid eligibility rules in your state.

Can I get help applying for Medicaid?

If you need help with eligibility for Medicaid and appealing a Medicaid decision, contact a local affiliate of the Legal Services Corporation (LSC). LSC is a federally funded organization with a mission to provide high-quality civil legal assistance to people with low-incomes. To find a LSC local affiliate, use the interactive map located on the LSC Web site.

Do I have to pay a premium for Medicaid coverage?

Generally, there are no premiums for Medicaid coverage. However, in some states, a premium might be charged for some eligibility groups.

What services are covered under Medicaid?

Medicaid coverage is generally comprehensive, and when there is cost sharing (such as co-pays for prescriptions), it is usually minimal. However, your benefits and services will depend on the state in which you live and the reason you became eligible. States have a lot of flexibility in defining the type of benefits and services that are offered under Medicaid. In most states, children and families in Medicaid must enroll in managed care plans to have their health benefits covered.

The best way to see what is covered under your state Medicaid program is to contact your State Medicaid program.

In addition, a nonprofit group called The Arc, has a Web site with general information about what Medicaid covers in each state.

What do I do if Medicaid denies coverage for something that I need?

You have the right to appeal a decision made by your state Medicaid program. In addition to the grievance process set up by your state Medicaid program, you have specific rights under Federal law to appeal a Medicaid denial.

If Medicaid denies you something that you need, you can appeal that decision through a Medicaid fair hearing. In addition, Medicaid fair hearing decisions can be appealed in court.

If you are enrolled in a Managed Care Organization (MCO) through a state Medicaid program, you also have the right to appeal through a Medicaid fair hearing. However, you may be required to exhaust your MCO appeal's process first. If this is the case, your Medicare MCO must resolve your appeal within 45 days for non-emergency appeals and 3 days for emergency appeals.

If you need help appealing a Medicaid decision, contact a local affiliate of the Legal Services Corporation (LSC). LSC is a federally funded organization with a mission to provide high-quality civil legal assistance to people with low-incomes. To find a LSC local affiliate, use the interactive map located on the LSC Web site.