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Everything You Need to Know about Medicaid Eligibility


Main Points

  • Medicaid is open to a variety of citizens who fall below the poverty line

  • Medicaid is a federal program but states can choose to provide Medicaid coverage to other groups as well

  • The ACA established federal regulations for modernized, data driven approach to verify financial and non-financial information to determine eligibility

Medicaid and Children's Health Insurance Program (CHIP) cover over 60 million Americans. The demographic that this includes span children, pregnant women, parents, seniors, and children with disabilities. The bare minimum eligibility level is determined on the federal poverty level (FPL), which is $24,250 annually for a family of four.

However, eligibility ranges depending on the individual, which we will get into in a moment.

When it comes to subsidizing the Medicaid program, the federal government and individual states contribute to cover the cost of those individuals. Each state can choose to expand or contract Medicaid as they see fit.

When states run a deficit and need to cut costs, this is seen most notably in the reimbursement rate for clinicians and cuts to community programs. This decision usually results in an increase in ER visits and over crowding in prisons.

Medicaid is open to a variety of citizens who fall below the poverty line. A person can be eligible for Medicaid if:

  • They are a U.S citizen or person who can provide proof of eligible immigration status

  • A Social Security number has been applied for

  • They meet the requirements for the AFDC program

  • They are a child under the age of 6 whose family incomes are at or below 133 percent of the federal poverty level

  • They are a pregnant woman with family income below 133 percent of the FPL

  • They receive supplemental security income

  • They are recipients of adoption or foster care

  • Fall under a special protected group

  • Or children born after 09/30/1983 are under 19 and in families with incomes at or below the FPL

Medicaid is a federal program but states can choose to provide Medicaid coverage to other groups as well.

While these are the federal guidelines for Medicaid eligibility, individual states can choose to provide Medicaid coverage to other groups that share some of the same characteristics. However, some of those groups that fall under Medicaid expansion are more broadly defined like the aged, blind, or disabled adults with income below the FPL or low-income institutionalized individuals.

CMS provides a list of Medicaid eligibility group which include:

  • Mandatory categorically needy (for example, low income families)

  • Optional categorically needy (for example, independent foster care adolescents)

  • Medically needy (for example, medically needy pregnant woman)

When you are seeing Medicaid patients, it is important that you verify their eligibility status given the above principles.

What if your patient doesn't fall under these categories, but is financially needy and has a commercial insurance plan?

This is a great question!

If you have a patient that is in financial need, not eligible for Medicaid coverage, and has a commercial insurance plan, you can go through a process to prove financial hardship or ask the payer if they would be willing to make an exception for writing off the copay or deductible amounts.

If you need help with this process, contact us and we would be happy to walk you through the process.

The ACA established federal regulations for modernized, data driven approach to verify financial and non-financial information to determine eligibility. States now rely on electronic data sources to confirm information included on the application, promote program integrity, and minimize the mount of paper documentation that people need to provide.

Due to the electronic nature of verifying the eligibility of Medicaid patients, coverage can come and go and change depending on the patients current financial status.

Therefore, it is imperative that medicaid eligibility be verified at every visit! Infants born to pregnant women whoa re receiving Medicaid at the time of delivery are automatically eligible for Medicaid until their first birthday.

Because eligibility is determined on a month to month basis, some Medicaid state agencies require that the provider check eligibility each time the patient is seen.

When it comes to Medicaid benefits, there are federal regulations stipulating mandated benefits for Medicaid. State Medicaid agencies can choose to provide other optional benefits through the state Medicaid program. Medicaid program must provide the mandatory benefits to eligible individuals in order to receive matching federal funds.

Below are some of the mandatory benefits:

  • Inpatient hospital services

  • Outpatient hospital services

  • Home health

  • Rural health clinics

  • Nurse midwife services

  • Physician services

Some of the optional benefits include:

  • Clinic services

  • TB testing

  • Case management

  • Dental services

  • Dentures

  • State Plan Home and Community Based Services

  • Other services as approved by the Secretary

In conclusion, it is necessary that as a provider of services to Medicaid patients that you check eligibility and benefits each and every session. While this may present an operational burden on your or your staff, it shouldn't be optional to get paid for services that are rendered.

It is very important that your patients receive your services and we want to enable your patients to receive long-term care as needed.

Feel free to reach out if you have any questions about your practice or your patients medicaid coverage and we would be happy to answer any questions that you may have!

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