Insurance

Medicaid FAQs


Q: Who is eligible for Medicaid?


  • A: Many groups of people are covered by Medicaid. These groups include those over 65, pregnant women, individuals with disabilities, and in some states, other low income adults. Certain requirements must be met for each group, and the requirements vary by state. Generally, though, your income and assets must be below certain limits. Some states use the income and asset limits of the Supplemental Security Income (SSI) program. Other states establish their own Medicaid limits. Somes states also grant Medicaid benefits to those who are "medically needy" -- they don't meet the low income limits until their medical expenses are taken into consideration.

    Only U.S. citizens and lawful permanent residents can receive Medicaid. Your child may be eligible for coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if you are not. There is an exception to the citizenship/residency requirement for people with emergency medical conditions. States are free to determine what conditions qualify for emergency treatment, but all states will cover emergency childbirth; some states will pay for chemotherapy, organ transplants, dialysis, and more.


Q: Are there any deductibles, coinsurance, or co-payments?


  • A: Your state's Medicaid program can charge small monthly premiums, copayments, and deductibles on most Medicaid-covered services. The amounts must be small and can vary depending on the Medicaid recipient's income and the cost of the service.

    Medicaid cannot charge children, terminally ill recipients, or individuals who live in an instituion like a nursing home. And no one can be charged for emergency services, family planning services, pregnancy-related services, or preventive services for children. Medicaid will often charge copays for physical therapy, occupational therapy, speech therapy, podiatry, prescription drugs, eyeglasses and exams, and prosthetic devices.


Q: What payments must providers accept?


  • A: Providers (doctors, pharmacies, hospitals, and so on) participating in Medicaid must accept the Medicaid reimbursement as payment in full. Each state has relatively broad discretion in determining their own reimbursement schedules and rates for services (within federally-imposed upper limits and specific restrictions).


Q: What are the limitations on Medicaid services?


  • A: Within broad federal guidelines and certain limitations, states determine the amount and duration of services offered under their Medicaid programs. States may limit, for example, the number of days of hospital care or the number of physician visits covered. The limits, however, must result in a sufficient level of services and they may not discriminate among beneficiaries based on medical diagnosis or condition.


Q: What is the difference between Medicare and Medicaid?


  • A: Medicare is an insurance program that working people pay into over many years through Medicare taxes. The program pays medical bills from the taxes collected. It primarily serves people over 65 and younger disabled people and dialysis patients. Patients pay part of costs of the program through deductibles and copayments for hospital stays and office visits. Medicare charges a monthly premium for non-hospital coverage (Part B). Medicare is a 100% federal program and is the same everywhere in the United States.

    Medicaid is an assistance program for low-income individuals. Medicaid is a federal-state program; it is largely funded by the federal government, but states can make their own rules regarding eligibility and services. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age (depending on the state). Medicaid can charge some recipients small copayments for services.


Q: When does coverage stop and start?


  • A: Coverage starts on the date the Medicaid application is filed or the first day of the month during which the application was filed. Medicaid coverage can also extend retroactively for up to three months prior to the application, if the individual satisfies the eligibility standards during that time. When a recipient no longer meets the requirements for eligibility, coverage will stop at the end of the month.


Q: Where do I apply for Medicaid?


  • A: Individuals who qualify for Medicaid can apply at their state Medicaid agency, state welfare offices, or certain social service agencies.


Q: Who do I contact with questions about Medicaid eligibility and benefits?


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