Medicaid FAQ

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

  • A:States may impose nominal deductibles, coinsurance, or co-payments on some Medicaid recipients for certain services. Emergency services and family planning services must be exempt from such copayments. Certain Medicaid recipients must be excluded from this cost sharing, including:

    • Pregnant women
    • Children under age 18
    • Hospital or nursing home patients who are expected to contribute most of their income to institutional care
    • Certain defined HMO enrollees

Q: How are payments determined?

  • A:Medicaid operates as a vendor payment program, with payments made directly to the providers. Providers participating in Medicaid must accept the Medicaid reimbursement level as payment in full. Each state has relatively broad discretion in determining (within federally-imposed upper limits and specific restrictions) the reimbursement methodology and resulting rate for services.

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. Two restrictions apply: (1) limits must result in a sufficient level of services to reasonably achieve the purpose of the benefits; and (2) limits on benefits may not discriminate among beneficiaries based on medical diagnosis or condition. In general, States are required to provide comparable amounts, duration, and scope of services to all categorically needy and categorically related eligible persons. There are two important exceptions:

    • Medically necessary health care services that are identified under the early and periodic screening, diagnostic, and treatment program for eligible children, and that are within the scope of mandatory or optional services under Federal law, must be covered even if those services are not included as part of the covered services in that State's Plan; and
    • States may request "waivers" to pay for otherwise uncovered home and community-based services (HCBS) for Medicaid-eligible persons who might otherwise be institutionalized

    As long as the services are cost effective, States have few limitations on the services that may be covered under these waivers (except that, other than as a part of respite care, States may not provide room and board for the beneficiaries). With certain exceptions, a state's Medicaid program must allow beneficiaries to have some informed choices among participating providers of health care and to receive quality care that is appropriate and timely.

Q: What is the difference between Medicare and Medicaid?

  • A:Medicare is an insurance program. Medical bills are paid from trust funds that those who are covered have paid into. It primarily serves people over 65 and younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Health Care Financing Administration, an agency of the federal government.

    Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments according to federal guidelines

Q: When does coverage stop and start?

  • A:Coverage may start retroactive to any or all of the 3 months prior to application, if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person's circumstances change. Most states have additional "state-only" programs to provide medical assistance for specified poor persons who don't qualify for the Medicaid program. No federal funds are provided for state-only programs.

Q: Where do I apply for Medicaid?

  • A:Individuals qualified for Medicaid can apply at local state welfare offices, state public health departments and state social service agencies.

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

Q: Who is eligible for Medicaid?

  • A:Many groups of people are covered by Medicaid. Even within these groups, though, certain requirements must be met. These may include your age, whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a U.S. citizen or a lawfully admitted immigrant. The rules for counting your income and resources vary from state to state and from group to group. There are special rules for those who live in nursing homes and for disabled children living at home.

    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 (however, there is a 5-year limit that applies to lawful permanent residents). Eligibility for children is based on the child's status, not the parent's. Also, if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child.

    In general, you should apply for Medicaid if you have limited income and resources.

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