If you’ve fallen on hard times, applying for Medicaid may not be the first item on your to-do list — but you might want to add it now. Medicaid is the public health care insurance program available to people and families with low incomes. It covers more than 72 million Americans, making it the single largest provider of health insurance in the U.S. If you have a medical condition or take expensive prescriptions, it can greatly help in your time of need.
Unlike Medicare, the federal health insurance program primarily for people ages 65 and older, Medicaid is run jointly by federal government and states’. So, although your state government determines many benefits, all state Medicaid programs must meet certain minimum federal standards.
Here’s what to learn about Medicaid, its coverage and eligibility.
How to qualify for Medicaid
Your eligibility for Medicaid is largely determined by where you live. The Affordable Care Act of 2010 gave states the option of expanding coverage to anyone earning less than 138 percent of the federal poverty level. You’d use your “modified adjusted gross income,” which is total income minus certain expenses and tax deductions, to figure it out. Healthcare.gov provides information on calculating modified adjusted gross income.
The income limit to qualify for Medicaid may increase for those who (are):
- Have children or disabled dependents.
- Have high medical bills due to an illness.
- Pregnant women or disabled.
If you have children but earn too much to qualify for Medicaid, you may be able to enroll them in the Children’s Health Insurance Program, or CHIP. If you are eligible for Medicaid, your entire family will be covered once you are accepted. Most states have expanded Medicaid, and more are on the way. If your state did not expand Medicaid and you do not have children, your chances of qualifying are slim.
What is the lowest income to qualify for Medicaid?
A single person aged 65 or older must earn less than $2,523 per month. This includes nursing home Medicaid, as well as assisted living and in-home care in states that offer it through HCBS Waivers. Reparations for Holocaust survivors and COVID-19 stimulus checks are not considered income.
For married applicants, income limits for nursing home Medicaid and HCBS Waivers are more complicated. When only one spouse applies, only that spouse’s income is considered. This means that the income of the non-applicant spouse is not considered when determining the applicant spouse’s income eligibility, which is limited to $2,523 per month.
Furthermore, some of the applicant’s monthly income can be allocated to the non-applicant spouse. This spousal protection, known as a Minimum Monthly Maintenance Needs Allowance (MMMNA), is intended to keep the non-applicant spouse from becoming impoverished. The maximum amount of income that can be allocated to a non-applicant spouse in most states is $3,435 per month. It should be noted that the non-applicant spouse’s income, when combined with the applicant spouse’s income allowance, cannot exceed $3,435 per month.
For married couples with both spouses applying, each spouse is allowed $2,523 per month, for a total monthly income of $5,046.
While nursing home Medicaid and HCBS Waivers typically have the same financial eligibility criteria, “Aged, Blind, and Disabled” (ABD) Medicaid can also provide in-home care. This type of income limit is usually much lower and more restrictive. ABD Medicaid is also known as Regular or State Plan Medicaid. In roughly half of the states, the income limit for ABD Medicaid is $841 per month for a single applicant or $1,261 for a married couple. In the remaining states, the monthly income limit for a single applicant is generally $1,133, or $1,526 for a married couple.
Unlike nursing home Medicaid and HCBS Medicaid Waivers, the income of the spouses is calculated together, even if only one spouse is an applicant. This means that the income of the non-applicant spouse affects the applicant spouse’s income eligibility. Another distinction is that non-applicant spouses of ABD Medicaid beneficiaries are not eligible for the Minimum Monthly Maintenance Needs Allowance.
What it pays for
Medicaid provides many of the same medical services as a traditional health insurance plan. Adults and children alike have low or no copays for hospitalization and doctor visits.
Despite the fact that states determine their own benefits, they are required to cover certain services. Medicaid will pay for the following health services in full:
- Emergency care.
- Family planning.
- Pregnancy-related services, including assistance quitting tobacco.
- Preventive-care services for children.
- Most other services for children under 18, unless they are in higher-earning households.
The following benefits are required in all states, but may come with a copay, depending on where you live:
- Hospital services, both inpatient and outpatient.
- Visits to the doctor
- EPSDT is an abbreviation for early and periodic screening, diagnostic, and treatment services.
- Nursing home care.
- Home health care services
- Health clinics in rural areas.
- Laboratory examinations.
- Services provided by a nurse midwife and a freestanding birth center.
- Pediatric and family nurse practitioners who are certified.
- Transportation to and from medical care.
In order for Medicaid to pay for your care, your doctor may need to demonstrate to the state that your treatment is necessary. This is referred to as “prior authorization,” and it is a technique used by all types of health insurers to reduce wasteful spending on specific services.
Under Medicaid, all states provide dental benefits to children, and most states also provide dental benefits to adults. According to a federal report released in June 2015, 27 states’ Medicaid programs cover preventive dental services for adults, while 26 states cover restorative services such as cavity fillings.
Only emergency dental care is covered by Medicaid in 19 states. The majority of states cover eye exams and glasses.
Each state can set premiums, deductibles, and out-of-pocket costs for some Medicaid recipients. Higher-income Medicaid recipients, defined as those earning at or above 150 percent of the poverty line, may have to pay more for the following health services:
- To encourage the use of lower-cost drugs, states may charge coinsurance of up to 20% of the drug’s cost for prescriptions.
- If members of this group visit the emergency room in a non-emergency, they may be charged the full cost of care. The hospital’s physicians must determine whether the visit was an emergency in this case.
Some higher-income individuals may also be required to pay small monthly Medicaid premiums. Children in California households earning 160 percent to 266 percent of the federal poverty level, for example, pay a monthly premium of $13 per child, according to Tony Cava, a spokesman for Medi-Cal, the state’s Medicaid program. Working disabled people in California can earn up to 250 percent of the federal poverty level and still “receive full-scope Medi-Cal by paying a low monthly premium based on countable income,” according to Cava.
What Medicaid doesn’t pay for
Medicaid, like many other health plans, does not cover cosmetic surgery and, in most states, does not cover holistic therapies such as acupuncture. States are not permitted to use federal funds to pay for elective abortions, but they are permitted to use their own budgets to cover abortion services through Medicaid.
According to the reproductive health organization Guttmacher Institute, seventeen states currently cover medically necessary abortions. A total of 32 states and the District of Columbia have Medicaid programs that will cover the procedure in cases of rape, incest, or where the mother’s life is in danger. South Dakota Medicaid only pays for abortions to save the mother’s life.
How to apply for Medicaid
You can apply for Medicaid at any time; no open enrollment period is required. You can apply for Medicaid if you believe your medical expenses may qualify you.
You can apply for Medicaid even if you already have health insurance, and switching plans outside of open enrollment will not result in a penalty. If you have insurance and are deemed eligible for Medicaid, you must cancel your current health plan.
If you think you make too much money to qualify for Medicaid, but your income is close to the eligibility levels, there are three good reasons to apply anyway:
- If you have a lot of medical bills, you may still be able to get coverage.
- If you have children, your application also serves as a CHIP application.
- Your state’s Medicaid office can assist you in locating alternative health insurance options.
You can apply for Medicaid through two channels: the ACA marketplace or your state’s Medicaid office. Following your application, you should receive more information on what to expect and how to use your Medicaid benefits, policy, email, search, contact, privacy, and so on.
The Medicaid program is a government health insurance program. It provides coverage to low-income individuals, families, seniors and people with disabilities who meet eligibility requirements. This program ensures that these individuals receive the healthcare coverage and care they need.