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Medicaid is a health insurance program for families and individuals that have low incomes. It’s a government insurance plan that provides access to health services to qualifying persons in all 50 states that do not have the resources to pay out of pocket for such services.

What is Medicaid?

Many families that include a child with a disability experience financial difficulties because of the enormous cost of medical interventions, and expenditures related to caring for their child.

Sometimes, financial duress is caused because a parent is forced to work fewer hours to care for his or her child. In other cases, money stress is the caused by medical treatment.

In these cases, low-income parents can in many cases turn to Medicaid, the US government-sponsored health program for poor Americans. Medicaid has also been a buzzword because access is being expanded throughout the United States as a result of the Patient Protection and Affordability Act.

The Medicaid system, however, can be difficult to navigate for a person seeking affordable access to the healthcare system. Here are some tips on how parents can procure Medicaid coverage for themselves, and their child.

About Medicaid

Medicaid is a health insurance program for families and individuals that have low incomes. It’s a government insurance plan that provides access to health services to qualifying persons in all 50 states that do not have the resources to pay out of pocket for such services.

As the largest source of funding for health services for poor Americans, the program is means tested and administered by state governments. Unlike Medicare, the health care source for Americans more than 65 years old, Medicaid is funded by both the federal government and the states, each of which pay 50 percent of its cost.

States operate their own Medicaid systems, which set requirements that applicants must meet to take part in the program. Because of this, requirements may vary. As the Patient Protection and Affordability Act is phased in, state-to-state requirements will likely become more consistent. All state Medicaid systems must adhere to federal guidelines.

Although participation in the Medicaid system is voluntary for states, all 50 have state Medicaid programs.

Medicaid does not pay benefits directly to individuals; it provides payments to health care providers that have agreed to accept Medicaid payments. Services that are not covered with Medicaid and small copays are the responsibility of the individual.

Why was Medicaid created?

Medicaid was created in 1965, when it was created as the result of an amendment to the Social Security Act. The program was created as an entitlement that would make health care services available to low income, vulnerable Americans.

The program was also devised to provide some flexibility for states, which share funding responsibilities. States establish their own Medicaid program in accordance with federal guidelines; what is, and is not covered varies from state to state. Income requirements and funding levels may also vary. All state-run Medicaid programs are monitored by the Centers for Medicare and Medicaid Services.

What does Medicaid cover?

In general, Medicaid covers a specific list of services. This list is comprised of most medical services a person would require; to what extent that services will be covered will be determined by state Medicaid programs. Additionally, some services have limitations and restrictions.

The services covered under most Medicaid programs include:

  • Hospitalization – Inpatient services covered include room fees, x-rays, laboratory services, and medication. Outpatient services include emergency room services, laboratory fees, x-rays, tests and drugs. Both inpatient and outpatient surgery are covered.
  • Nursing care – Covers room and board, therapies, and medical supplies.
  • Clinic care – Covers outpatient medical services.
  • Hospice – Covers medical care to individuals that are terminally ill.
  • Physician’s visits – Covers service fees, laboratory work, and most associated treatments.
  • Prescription drugs – Pays for most, but not all, prescription medications. Also pays for medical devices and supplies.
  • Chiropractor services – Covers appointments for spinal manipulation, as well as x-rays.
  • Dental care – Covers cleanings, fillings, extractions, services crowns and dentures.
  • Diagnostic services – Covers tests and screening to treat medical conditions.
  • Mental health services – Covers psychological and psychiatric evaluations, inpatient services, individual therapy sessions, and residential treatment.
  • Home health care – Pays for in-home nursing care provided by an approved agency.
  • Durable medical equipment – Covers supplies need to ensure a patient’s health, such as catheters, or oxygen.
  • Ambulance services – Covers ground ambulance services when it is deemed medically necessary.
  • Vision care – Pays for eye exams, eyeglasses and contact lenses to correct eye conditions.
  • Therapy – Covers physical, occupational and speech therapies.

Services that are not on a state’s list of approved services may be covered if an individual applies for, and is granted a Medicaid waiver. Waivers were designed to cover services that would help and individual that would be otherwise institutionalized or placed in a nursing facility.

One aspect of Medicaid-covered services that is of interest to parents of children with disabilities is the Fee for Service Program, which reimburses schools for services provided to special education students. This only applies to children that are Medicaid-eligible.

When a person seeks medical treatment under Medicaid, what happens?

Most state Medicaid programs enroll eligible families into privately-managed health plans. Because of this, when families seek medical care, they will need to follow the guidelines set forth by the health plan to ensure that services are covered at a maximum level. The health plan is then responsible for providing health care to enrollees.

But if a person is older, or is disabled, he or she will likely remain in traditional “fee for service” Medicaid. That means that they will take their health care concerns to a physician-provider that has agreed to accept payment from Medicaid.

Like visiting the physician’s office with conventional medical insurance, individuals may have to cover deductibles and copayments.

What are the eligibility requirements for Medicaid?

At a local level, Medicaid is administered by state governments, and although some requirements may vary, the general factor that is going to be the most important aspect of an application is a person’s income.

What is most surprising to Medicaid applicants is that there are several provisions in place that can determine if a person is Medicaid-eligible. Some of the circumstances that can determine Medicaid eligibility are set by statute.
Some circumstances that can determine eligibility include:

  • A person’s immigration status
  • If a person has a disability
  • If a person under the age of 18 or 21
  • If a woman is pregnant
  • An applicant’s assets
  • An applicant’s age

The Patient Protection and Affordable Care Act expanded Medicaid eligibility to persons earning 133 percent of the federal poverty level, which is about $28,500 for a family of four. However, because some states are still determining when, or if, they will expand Medicaid within their states, applicants will need to make an effort to learn about whether they are eligible for coverage.

However, in most cases, an individual with significant disabilities that meet income guidelines, will automatically qualify for Medicaid if the family receives Temporary Assistance for Needy Families, or TANF, benefits, or has been determined to be eligible for Supplemental Security Income assistance, they will likely be eligible for Medicaid coverage.

The main requirements that a Medicaid applicants must meet include:

  • Must be a US citizen or legal resident
  • Must be at, or below, federal poverty guidelines
  • Must live in the state where they apply for assistance
  • Must meet all state requirements regarding assets, income, marital status and age

There are some special provisions on the book for children with disabilities. A child that is living at home with his or her parents may be eligible for Medicaid coverage even if parents are not eligible. And, if a child with disabilities does not live with his or her parents, he or she may still e eligible for coverage even if his or her guardians are not eligible.

Although provisions that govern children with disabilities differ from state to state, parents will likely have to prove:

  • Their assets are not too high to disqualify a family from coverage
  • A child is 19 years old or younger
  • A child is determined to be disabled under the rules used by the Social Security Administration
  • A child requires a level of care typically provided in a medical setting
  • A child can be provided for safely and appropriately in his or her home
  • The costs incurred for a child to be cared for do not exceed those that would be incurred in an institutional setting

If approved, Medicaid coverage can be retroactive for up to three months prior to the date of application. If a person becomes ineligible for Medicaid assistance, coverage will cease at the end of the month the applicant is no longer eligible.

What is the Medicaid application process?

Individuals that would like to pursue Medicaid coverage should first stop by their state human service or public health office. These governmental departments may have different names, but they all have the same goal in terms of providing the necessary documents, information and resources a person requires to submit a complete application.

To date, all states have an application process that begins online. Applications can be completed and emailed to caseworkers through an online form, or it can be printed and mailed to the proper contacts. However, an applicant will likely be asked to attend a meeting with a caseworker to go over their application, and provide additional paperwork.

An applicant should be able to provide a caseworker the following paperwork:

  • IRS tax forms and returns
  • Employment pay stubs
  • Mortgage agreements or statements
  • Rental leases
  • Bank statements
  • Birth certificates for all members of the family
  • Citizenship, resident alien or naturalization paperwork
  • Medical information about every member of the family
  • SSI and TANF information and determinations

Because eligibility is based primarily on income, an applicant should be prepared to give detailed information about his or her financial status to a Medicaid specialist.

Once an application has been received by the state Medicaid department, an assessment will determine whether a family, or a child, meets the eligibility requirements. Some states send a child’s information to a disability determination service to determine whether a child is considered disabled under Social Security standards. Medicaid will likely send what is called a “Certification for Disabled Children Living at Home” inquiry to a child’s physician to determine if standard of care provisions are met, and to obtain other medical information.

A parent will be notified in writing whether an application is approved or denied. The letter should also indicate that the determination can be appealed, and how a parent should go about scheduling a hearing.

What happens if my application is denied?

If an applicant is denied Medicaid coverage, he or she may seek a Medicaid Fair Hearing. This hearing takes place in front of an administrative law judge, who will listen to the reasons an applicant believes he or she should have their application, or a specific service, covered. The judge will then decide if a re-determination is warranted.

But generally, state Medicaid agencies attempt to resolve conflicts before it gets to this stage. Recipients should remember that’s it’s within the Medicaid program’s rights to enforce rules about what is covered and what is not. Recipients are also only entitled to the least expensive treatment that is adequate to solve a medical issue.

If a parent receives a denial notice, he or she will have about 45 days to respond to the letter and request a hearing. Generally, the best plan is to reply to the letter as soon as possible to preserve fair hearing and due process rights.

Is Medicaid portable?

Because Medicaid is administered by state agencies, it is not portable in a traditional sense. If a Medicaid recipient decides to relocate, he or she will have to re-apply in their new state for services. And, because state criteria differs, there’s no guarantee that an applicant will be covered.

The best way to ensure that Medicaid services are preserved is to plan. The first step to securing coverage in a new state is to report your plan to move your current state’s caseworker so he or she can close out a file in the proper manner. When you arrive in your new state, apply for Medicaid as soon as possible.

The best course of action is to make sure you thoroughly research a state’s Medicaid coverage criteria before moving to make sure a transition is a seamless and stress-free as possible.

Does you qualify for Medicaid waivers? Unsure?

Visit Medicaid Waivers for more information.

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