Medicaid Explained

Affording basic medical care

Many people today need assistance in affording basic medical care. They may not be able to afford sufficient medical insurance to cover their health care costs, or their jobs may not provide them with sufficient coverage through employee-based health care plans. This is where Medicaid can come in, providing assistance to individuals who have lower income levels and giving them increased coverage for basic health care. It can also help those who are disabled as well as some older Americans.

Today, there are many people who do not understand the basics of the Medicaid program and do not know whether they may qualify for this assistance. This article will look at some of the most basic questions that people ask about Medicaid, including the following:

• What is Medicaid?
• Who created Medicaid?
• When was Medicaid introduced?
• How is Medicaid different from Medicare?
• Who is eligible for Medicaid?
• How can you get Medicaid coverage?

What Is Medicaid?

Medicaid is an assistance program run by both the federal government as well as individual state governments. It is designed to provide financial assistance for a variety of medical needs to those individuals who are least likely to be able to afford it while also being most likely to need appropriate health care. Medicaid programs come under the direction of the United States Centers for Medicare and Medicaid Services, which provides broad guidelines. However, each state then runs the individual program for its residents. In general, each state is responsible for the following tasks.

• Determining specific eligibility requirements
• Listing services covered, including duration of services
• Setting pay rates
• Providing the overall administration of Medicaid

There is a surprisingly broad group of Americans that use Medicaid with up to one in five individuals in the country currently enrolled. Because of this, funding for this form of social welfare is huge, which is one reason why it must be a federally run program. One of the key guarantees within Medicaid is that the federal government will match the dollars provided by the states at a predetermined rate with no cap on money spent. The federal government must match at least 50 percent of dollars spent on Medicaid in all states and often matches much more than this in less wealthy states.

Medicaid is often carried out through private managed care plans from companies under contract to the state. However, some use pay-for-service plans instead. Whichever option is chosen, Medicaid beneficiaries are generally far better off medically speaking than the uninsured cohort is because they have far better access to quality health care. When they do not have to worry as much about the cost of basic health care, they are far more likely to see their doctors when they have an issue and to undergo preventive care and basic screening services, which can reduce the risk of major chronic diseases and costly health issues in the future.

The History of Medicaid

Medicaid has not always been a part of the American medical and legislative landscape and, in fact, only recently came into existence. Who created Medicaid? This social welfare program was developed through legislation under Lyndon B. Johnson’s administration when the Social Security Act was amended.

When was Medicaid introduced? This first happened in 1965 when the Aid to Families with Dependent Children (AFDC) was introduced to provide cash assistance to needy families. However, over time, many important changes were made to the Medicaid program. For example, the Supplemental Security Income policy was eventually enforced to provide financial aid to individuals with certain disabilities.

Throughout the years, the federal government has expanded the Medicaid program but has always given individual states the opportunity to opt into or out of the program. In addition, there are ways for states to request certain alterations to the program to meet needs specific to their regions.

In 1990, the United States began the Medicaid Drug Rebate Program along with the Health Insurance Premium Payment Program to aid in paying for prescription drugs for needy individuals. With 1993’s Omnibus Budget Reconciliation Act, the Drug Rebate Program was changed slightly, and further changes were made to give states the ability to sue estates for long-term care costs for elderly individuals who had died while on Medicaid.

Finally, further changes were made in 2010 under the Patient Protection and Affordable Care Act to provide Medicaid assistance for individuals who were making up to 138 percent of the Federal Poverty Limit. It also provided reimbursements to states at gradually decreasing levels throughout the ensuing years to help them cover these new charges. However, a Supreme Court ruling in 2012 made this expansion plan optional.

Thanks to changes under the Affordable Care Act (ACA), more people than ever, including large portions of children, are now able to receive proper medical care that they never otherwise would have been able to afford. The history of Medicaid has not always been smooth, but it has reflected legislators’ wishes to protect the least fortunate Americans from a lack of sufficient medical coverage.

Results of Medicaid Programs

The benefits of the Medicaid program have been astronomical for millions of Americans over the years. As of December 2019, nearly 64 million United States citizens were covered by Medicaid for the following year. This number shows that nearly 17 percent of all Americans are covered by this program today. Projected numbers show that up to 79 million Americans will be covered within the next two to three years. The amount of money put into this program is equal to 16 percent of the United State’s expenditures in health care.

Today, the majority of people covered by Medicaid are children as well as older individuals who no longer hold down full-time jobs. Approximately 45 percent of participants are 19 years old or younger while approximately 11 percent are 65 years of age or older. In addition, disabled adults make up 13 percent of the participants.

In 1966, as Medicaid was being introduced, Lyndon B. Johnson said, “Medical care will free millions from their miseries. It will signal a deep and lasting change in the American way of life.” Indeed, this is just what has happened as can be seen over the years since Medicaid began.

As of 2000, Medicaid had helped a cumulative number of 93 million Americans with health care that they never could have otherwise afforded, and it has helped tens of millions more since then. At the time of Medicaid’s 50th birthday in 2015, research showed just how much the program has helped. States that have implemented Medicaid and that have expanded service offerings under the Affordable Care Act have seen far fewer uninsured people, which has resulted in far less uncompensated care at hospitals. In fact, in 2014, research showed that there was a 7.8 percent decrease in uncompensated care when compared to the year prior.

In addition to these fabulous findings, research has also shown that Medicaid enrollees are quite happy with the quality of care available to them. In 2015, 90 percent of enrollees stated that they were happy with their Medicaid coverage, including the variety of doctors that were covered in their plans. This has then helped to provide better compensation to doctors and health care organizations that provide care to these populations.

Some of the other positive results of the Medicaid program in the United States include the following:

• Significant reduction in unpaid medical bills of over $3 billion following Medicaid expansion under the Affordable Care Act
• Improved health over one’s lifetime for Medicaid recipients
• Reduced infant mortality at the beginning of Medicaid in the 1960s and following expansion
• Improved treatments for substance abuse
• Improvements in hospital profitability

Key Features of Medicaid Programs

While they differ by state, most Medicaid programs cover a wide range of medical services for hundreds of thousands of residents who have low incomes or disabilities or for the children of those with low incomes. In addition, children can receive comprehensive dental services under these plans. Some of the key components of Medicaid coverage include the following:

• Prenatal care
• Recommended immunizations for children
• Doctor visits for children and adults
• Nursing care for adults over the age of 21
• Rehabilitation services
• Laboratory and radiology services
• Numerous recommended screenings and diagnostic tests
• Transportation services
• Physical therapy

Depending on the program, some of these services are optional. For example, certain states cover vision care and prescription drugs as well. Others choose not to provide physical therapy or transportation coverage. However, in general, the services that are included are those that are most likely to result in improved health as one ages via preventive and ambulatory care.

By far, the largest amount of coverage goes to children who receive routine care to ensure that they grow and develop correctly. In addition, states that have chosen to take part in the Medicaid expansion under the Affordable Care Act must provide the 10 essential health benefits in their plans, which include a wide range of preventive and mental health services.

One of the most important features of Medicaid is that it exponentially improves access to care for low-income individuals across the board. These are the people who are most likely to avoid seeking important preventive care because of lack of funds or who will live with an illness or injury for some time before seeking care. However, by providing proper care more quickly through Medicaid-approved providers, these individuals can actually get lower-cost care and can experience better health as they age. In fact, some research shows that children who are covered by Medicaid have lower teen mortality rates, fewer emergency room visits throughout their lives and decreased chances of disability when compared to the uninsured cohort.

Differences Between Medicare and Medicaid

Because of the similarities in their names, Medicare and Medicaid are frequently confused. While they both provide assistance for people who need health care in the United States, they are fundamentally different. For example, one of the key features of Medicaid is that it is provides financial assistance for health care costs to those with low incomes. On the other hand, Medicare is provided to senior citizens and is not based at all on income levels. Instead, anyone who has paid into the Medicare system in the past through federal taxes is able to receive this assistance.

Medicare should be seen more as a type of insurance for the elderly. While working, individuals will have money taken out of each paycheck or will need to pay into the Medicare system through estimated taxes. The entire Medicare program is covered by the United States federal government and is overseen by the United States Centers for Medicare and Medicaid Services. This is different from Medicaid, which is a federal-state partnership. Unlike Medicare, Medicaid is not funded directly through special taxes taken out of paychecks.

Most of the time, individuals are either on Medicare or on Medicaid. However, there are certain circumstances in which individuals qualify for both types of coverage. In these cases, which are known as dual eligibility, individuals will find that nearly all of their health care bills are covered at no cost to themselves.

Who Is Medicaid for?

Medicaid is generally available to those who fall beneath a certain income level. The Federal Poverty Level is usually used to determine this. In states that have expanded Medicaid coverage, individuals must usually fall below 138 percent of the Federal Poverty Level. However, other states that have chosen not to expand their coverage may have more stringent income requirements.

According to the Affordable Care Act, a Modified Adjusted Gross Income (MAGI) is used to determine eligibility for the majority of adults and children but not for those who are disabled or for senior citizens. In addition to low-income families, certain pregnant women and children as well as those who are currently receiving Supplemental Security Income may also be eligible for coverage.

While income status is the largest determinant for receiving Medicaid, individuals and families must also meet several other requirements. For example, they must be citizens or qualified non-citizens of the United States and must be residents of the states in which they are applying for coverage. Some requirements may also apply to pregnancy status or to age. For example, the elderly who need care in a nursing home may be able to meet qualifications. In addition, some people may be denied coverage even if they have low monthly income if they have other large assets.

Those who are denied coverage are allowed to appeal the process through a fair hearing. Each state has a different set of rules regarding this process. Some states choose to have the Medicaid agency run the hearing while others delegate the task to another agency or board.

Medicaid Costs

As a joint federal-state program, costs for Medicaid are shared by both the federal government and state governments. The federal government matches many of the costs at a predetermined rate. As previously mentioned, federal matching is available at a minimum of 50 percent for even the wealthiest states. However, poorer states may receive a much higher matching rate based on the average income per capita.

Because Medicaid covers so many people and pays for such a large variety of medical expenses, it is clearly a large budgetary item for any state as well as for the United States as a whole. In addition, funding has continued to expand since 1965 when the program was begun. For states, nearly 17 percent of the annual budget on average goes to Medicaid funding. When federal government funding is added in, Medicaid requires nearly 22 percent of a state’s budget.

Keep in mind that Medicaid does not send money directly to those who are covered. Instead, it pays health care workers and facilities for charges involved with inpatient and outpatient care. Some costs may be slightly offset by a patient-covered copayment, which is required in certain cases.

With changes through the Omnibus Budget Reconciliation Act of 1993, states were allowed to make up some of their income for Medicaid by suing the estates of deceased individuals who had passed away while on Medicaid. However, these funds can mainly be used to pay for long-term care expenses for those who are over the age of 55.

How to Get Medicaid Coverage

The only way to get Medicaid coverage is through your state. This is also a good place to go to get Medicaid explained to you or to find out specific requirements that your state has for eligibility. The official Medicaid Website of the federal government has information on contacting each state’s Medicaid office. Most Websites will have a section allowing individuals to check their eligibility before starting the application process online.

Unlike health insurance, which usually has an open enrollment period at the end of each year, you can apply for Medicaid at any time during the year. You will probably need to fill out a paper application and mail it in to your local office, or you may be able to complete your application online. In addition to the initial application, you will also need to supply some additional documentation proving your identity and the state of your finances. The necessary documentation could include the following:

• Proof of age and citizenship, such as from a birth certificate
• Recent pay stubs or a copy of a federal tax return
• Recent bank statement
• Proof of residency, such as from a lease or a recent bill
• Applicable medical records

States are required to process your application fully within 45 days. However, they are given an additional 45 days for processing if you are applying for Medicaid due to a disability rather than low income.

Medicaid provides vital health care assistance for millions of people throughout the United States who would otherwise not be able to afford basic health care for themselves or their families. It also helps the elderly who have limited resources to be able to age gracefully and healthfully, providing them with certain home health services and rehabilitation. Even if you think that Medicaid is not available for you or your family, you may be surprised to learn just how many people qualify for the program every year.

Getting Medicaid explained can help you understand whether it could be a good solution for you. In fact, due to some of the recent changes to Medicaid, including certain state Medicaid expansions, you may be surprised to learn that you could be eligible now even though you were not eligible in prior years. Consider checking with your state this year to see if you are eligible for services, and remember that each state is able to set many of its own qualifications for coverage.