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Medicaid Benefits

Medicaid is a state and federally funded health care insurance program available for low-income individuals and families as well as those who can demonstrate need.  There are over 25 different categories under which a person can be eligible for Medicaid benefits.  A person who falls into any of these categories will be eligible for Medicaid benefits.  The eligibility categories can be classified into five broad coverage groups that include children, pregnant women with children, adults with dependent children, individuals over age 65, and those with disabilities.  In addition, certain low income Medicare beneficiaries may also be eligible for Medicaid.  The Medicaid optionally-eligible Medicaid beneficiaries will vary from state to state.

The Medicaid program is called by different names in different states.  For example, the California Medicaid program is named MediCal, while in Georgia it’s called Georgia Better.  Though Medicaid eligibility differs from state to state, generally individuals who are members of a mandatory or optional group are eligible for Medicaid benefits.  All states are required to cover mandatory groups, but individual states can choose whether to cover groups categorized as optionally eligible.  Individual states can also use their discretion to provide benefits for some optionally eligible groups.  For example, individuals who would be eligible for Supplemental Security Income if they were not in medical institutions or individuals receiving only state supplemental payments can be made eligible for Medicaid benefits by the states.

Medicaid will pay for Medicare Part A premiums of a disabled person who has lost his/her Medicare coverage because of work.  However this happens only in cases where the disabled person’s income is below 200% of the poverty level and resources are no more than twice the standard allowed under Supplemental Security Income.

In order for state run Medicaid programs to be eligible to receive federal matching funds, there are certain basic services that must be offered to categorically needy populations.  The health care help available through this program must include service such as:

  • Inpatient and outpatient hospital services
  • Payment of physician services
  • Surgical and medical dental services
  • Nursing facility (NF) services for individuals aged 21 or older
  • Home health care for persons that are eligible for nursing facility services
  • Family planning services and supplies
  • Nurse / midwife services
  • Laboratory services and X-rays
  • Pediatric and those services provided by a family nurse practitioner
  • Federally-qualified health center services and ambulatory services that are otherwise covered under a   state plan
  • Rural health clinic services and other ambulatory services that are otherwise covered under a state plan

The most commonly covered health care services under an optionally eligible Medicaid program include:

  • Services provided by clinics
  • Prescription drugs
  • Prosthetic devices
  • Dental insurance
  • Services of an optometrist including eyeglasses
  • Nursing facility services for individuals under age 21
  • Intermediate care facilities and other services for the mentally retarded

States may also provide home or community-based care waiver services to certain individuals who are eligible for Medicaid.  Such services can include case management, personal care services, respite care, adult day health services, and home health aides.

Individual states determine both the amount and duration of Medicaid benefits offered under their programs.  Generally, federal guidelines require that the amount, duration, and scope of each service be sufficient to reasonably achieve its purpose.  States are responsible for placing appropriate limits on Medicaid services based on medical necessity and other types of controls.

Usually, Medicaid beneficiaries are allowed to choose among participating health care providers.  States may also elect to run their programs through prepayment arrangements such as a health maintenance organization or HMO.

Under the Medicaid program, payments are made directly to participating health care providers.  These providers are required to accept Medicaid reimbursements as payments in full.

States are allowed to charge small deductibles, coinsurance and co payments to certain Medicaid recipients and for certain services.  However, states are not allowed to charge copayments for emergency care and family planning services.  In addition, pregnant women, children under age 18, hospital or nursing home patients who are expected to contribute most of their income to institutional care, and categorically needy HMO enrollees are also exempt from copayments.

Initially, Medicaid was a medical care extension of federally funded income maintenance programs for the poor, with an emphasis on the aged, the disabled and dependent children and their mothers.  Over time, however, Medicaid has been diverging from a firm tie to eligibility for cash programs.  Recent legislation have ensured that Medicaid coverage is expanded to a number of low-income pregnant women, poor children, and some Medicare beneficiaries who are not eligible for any cash assistance program, and would not have been eligible for Medicaid under earlier Medicaid rules.  Legislative changes focus on enhanced outreach toward specific groups of pregnant women and children, increased access to care, and improved quality of care.  Legislation also continues specific benefits beyond the normal run of Medicaid eligibility and placed some restrictions on States’ ability to limit some services.

In addition to the increase in numbers of beneficiaries from new legislation, the most pronounced Medicaid service-related trends in recent years have been the continued sharp increase in expenditures for intensive acute care and for home health and nursing facility services for the aged and disabled.

The most significant trend in service delivery of Medicaid is the rapid growth in managed care enrollment within Medicaid.  One vehicle for the expansion of managed care, and of new eligibility groups, is the waiver process under Medicaid which allows States increased flexibility to research health care delivery alternatives while controlling program costs.  Another vehicle is the waiver authority which permits States to implement managed care delivery systems within prescribed parameters.

Inside Medicaid Benefits