Medicaid who is covered

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Medicaid programs serve specific groups of people, including: Pregnant women with low income Children of low-income families Children in foster care People with disabilities Seniors with low income Parents or caregivers with low income States can also choose to expand eligibility to other groups, such as people with low income who may or may not have children. What is CHIP? Medicaid by the numbers. What care services are covered by Medicaid?

Mandatory Medicaid benefits. Inpatient hospital services. Prescription drugs. Outpatient hospital services. Clinic services. Physical therapy. Nursing facility services. Occupational therapy thinking and movement. Home health services. Speech, hearing and language disorder services. Physician services. Respiratory breathing care services. Rural health clinic services. Other diagnostic, screening, preventive and rehabilitative services.

Federally qualified health center services. Podiatry foot care services. Laboratory and X-ray services. Optometry vision services. Family planning services. Dental services. Nurse midwife services. Certified pediatric and family nurse practitioner services. Prosthetics to replace missing or damaged body parts. Freestanding birth center services when licensed or otherwise recognized by the state.

Transportation to medical care. Chiropractic services. Expansions in Medicaid coverage of children marked the beginning of later reforms that recast Medicaid as an income-based health coverage program.

Prior to the ACA, individuals had to be categorically eligible and meet income standards to qualify for Medicaid leaving most low-income adults without coverage options as income eligibility for parents was well below the federal poverty level in most states and federal law excluded adults without dependent children from the program no matter how poor. The ACA changes effectively eliminated categorical eligibility and allowed adults without dependent children to be covered; however, as a result of a Supreme Court ruling, the ACA Medicaid expansion is effectively optional for states.

Under the ACA, all states were required to modernize and streamline Medicaid eligibility and enrollment processes. Expansions of Medicaid have resulted in historic reductions in the share of children without coverage and, in the states adopting the ACA Medicaid expansion, sharp declines in the share of adults without coverage.

Many Medicaid adults are working, but few have access to employer coverage and prior to the ACA had no options for affordable coverage. Figure 3: Medicaid has evolved over time to meet changing needs. In FY , Medicaid covered over 75 million low-income Americans. As of February , 37 states have adopted the Medicaid expansion. Data as of FY when fewer states had adopted the expansion show that States can opt to provide Medicaid for children with significant disabilities in higher-income families to fill gaps in private health insurance and limit out-of-pocket financial burden.

Medicaid also assists nearly 1 in 5 Medicare beneficiaries with their Medicare premiums and cost-sharing and provides many of them with benefits not covered by Medicare, especially long-term care Figure 4. Figure 4: Medicaid plays a key role for selected populations. Medicaid covers a broad range of services to address the diverse needs of the populations it serves Figure 5. In addition to covering the services required by federal Medicaid law, many states elect to cover optional services such as prescription drugs, physical therapy, eyeglasses, and dental care.

Medicaid plays an important role in addressing the opioid epidemic and more broadly in connecting Medicaid beneficiaries to behavioral health services. EPSDT is especially important for children with disabilities because private insurance is often inadequate to meet their needs. Unlike commercial health insurance and Medicare, Medicaid also covers long-term care including both nursing home care and many home and community-based long-term services and supports.

More than half of all Medicaid spending for long-term care is now for services provided in the home or community that enable seniors and people with disabilities to live independently rather than in institutions. Some states have obtained waivers to charge higher premiums and cost sharing than allowed under federal rules. Many of these waivers target expansion adults but some also apply to other groups eligible through traditional eligibility pathways.

Over two-thirds of Medicaid beneficiaries are enrolled in private managed care plans that contract with states to provide comprehensive services, and others receive their care in the fee-for-service system Figure 6. Managed care plans are responsible for ensuring access to Medicaid services through their networks of providers and are at financial risk for their costs.

In the past, states limited managed care to children and families, but they are increasingly expanding managed care to individuals with complex needs. Close to half the states now cover long-term services and supports through risk-based managed care arrangements.

Community health centers are a key source of primary care, and safety-net hospitals, including public hospitals and academic medical centers, provide a lot of emergency and inpatient hospital care for Medicaid enrollees. Medicaid covers a continuum of long-term services and supports ranging from home and community-based services HCBS that allow persons to live independently in their own homes or in other community settings to institutional care provided in nursing facilities NFs and intermediate care facilities for individuals with intellectual disabilities ICF-IDs.

This is a dramatic shift from two decades earlier when institutional settings accounted for 82 percent of national Medicaid LTSS expenditures. Figure 6: Over two-thirds of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs. A large body of research shows that Medicaid beneficiaries have far better access to care than the uninsured and are less likely to postpone or go without needed care due to cost.

Moreover, rates of access to care and satisfaction with care among Medicaid enrollees are comparable to rates for people with private insurance Figure 7. Medicaid coverage of low-income pregnant women and children has contributed to dramatic declines in infant and child mortality in the U. According to federal Medicaid regulations, this type of coverage is optional, but all states choose to offer it, and it covers nearly all FDA-approved medications, which the program purchases at cost, thanks to rebates and special agreements with pharmacies.

Medicaid covers certain mandatory medical services similar to those offered by Original Medicare Parts A and B. These include the following:. States have the option to offer additional benefits, such as dental and vision. Other optional benefits include:. Additionally, Medicaid will not pay for:.

Medicaid is a federal entitlement program that offers guaranteed coverage to all qualifying residents. Certain individuals, including low-income families, pregnant women and adults who are blind or disabled, are included in mandatory eligibility groups.

States may also offer optional coverage to individuals who are categorically needy. This includes seniors who receive home- and community-based services, are on hospice, live in a nursing home or are in poor health. Because each state operates its own Medicaid program within the federal framework, income limits and medical eligibility requirements vary by state.

At least 42 states have adopted the optional Special Income Level standard for Institutional Medicaid. Other states, such as California, Hawaii and Kansas, require seniors to use all or nearly all of their income for institutional long-term care before Medicaid kicks in. Fortunately, there are other ways for individuals who have substantial medical needs to qualify for Medicaid. Since Medicaid is never simple, there are also a number of exemptions.

The American Council on Aging provides a state-by-state eligibility guide. You can visit MedicaidPlanningAssistance. Institutional Medicaid only pays for skilled nursing if individuals need this level of care. Most states require seniors to complete a functional needs assessment as part of the application process. This assessment typically takes 45 minutes to an hour to complete.

These answers are then scored and used to determine an overall rating. To qualify for Institutional Medicaid or Long-Term Services and Supports that are covered by Medicaid waivers, applicants typically must require assistance with at least two activities of daily living. If you think you may qualify for Medicaid, you must apply for coverage in your primary state of residence. Benefits are available to U. Out-of-state coverage is limited unless you experience a life-threatening emergency or are unable to access necessary services in your home state.

The only way to see if you qualify for Medicaid is by completing an application. However, before you do, consider working with a Certified Medicaid Planner CMP to ensure the best chances for success. They must meet strict standards for education and work experience before they can sit for this exam.

CMPs include attorneys, accountants, social workers, financial advisors and geriatric care managers. Some CMPs charge for their services, while other organizations offer free assistance, thanks to private donations and community block grants. You can find a professional in your community by calling or contacting your local senior center, legal aid society or Area Agency on Aging.

The American Council on Aging also offers a free service that can check your eligibility and match you with a qualified advisor before you need long-term care.

There are a few ways that Medicaid can help with the cost of long-term care:. To receive long-term care benefits, you must require a nursing home level of care as determined by a functional needs assessment that gauges your ability to perform activities of daily living, such as cooking, bathing, dressing and toileting.