Medicaid Basics

Most Americans utilize third-party healthcare coverage to deal with their medical expenses. That means a company, whether public or private, pays medical expenses on behalf of the enrollee. As an enrollee, you pay a premium to the company, typically every month. 

One such public program in the US is Medicaid. Here you’ll find a basic guide to Medicaid coverage, who can use it, and how to apply for it. 

What Is Medicaid?

Its purpose is to provide free or low-cost healthcare coverage for low-income families, pregnant women, senior citizens, and individuals with disabilities.

Medicaid is a federal public health insurance program offered in conjunction with state governments. The federal government guarantees some funds to each state to administer Medicaid programs. Each state adds additional funds and administers the programs. 

Who Funds Medicaid?

The Medicaid program does not directly provide healthcare. The vast majority of beneficiaries have coverage through private care plans managed by Medicaid. In some states, Medicaid pays doctors, hospitals, nursing homes, and other medical facilities for services rendered to eligible patients. Not all medical care providers are required to accept Medicaid, and many do not. 

For every dollar that a state spends on Medicaid, the federal government matches it with at least one dollar. Poorer states receive higher matches than wealthier ones. Some state Medicaid programs are funded up to 73% by the federal government. The national average for federal funding is about 58% of a state’s Medicare budget.

Medicaid History

Title XIX of the Social Security Act authorized the Medicaid program in 1965. All states, US territories, and the District of Columbia have administered Medicaid programs since then. The states must follow certain parameters set by the federal government.

However, those standards are broad. States have flexibility in conducting the program, resulting in variations in coverage from state to state.

Historically, Medicaid is a highly effective program for providing insurance coverage to vulnerable populations in the US. Since the expansion of Medicaid under the Affordable Care Act in 2014, the number of uninsured Americans has dropped from approximately 45 million to about 29 million.  

What Does Medicaid Cover?

States must follow federal rules for providing mandatory services under their Medicaid programs. Hospital and physician care, laboratory work, X-rays, home health services, and nursing facility services for adult patients are all required.

They must also provide comprehensive services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children under 21 years old. 

There is a slate of optional services that many states offer under Medicaid. Although these services are not required by federal rules, they are vital to meeting the healthcare needs of benefit recipients.

All states provide prescription drug coverage under Medicaid. Many states also cover vision and dental care, hearing aids, and personal care services for people with disabilities and frail seniors. 

Who Is Covered By Medicaid?

As an “entitlement” program, anyone who meets the eligibility standards has the right to enroll in the Medicaid program. The federal government guarantees a portion of the funds needed for Medicaid programs. 

States must accept some mandatory populations under Medicaid coverage to be eligible for federal monies. 

  • Children through 18 years old from families whose income is below 138% of the federal poverty line. 
  • Some parents or caregivers with very low incomes
  • Pregnant women who have an income below 138% of the federal property line
  • Most senior citizens for people with disabilities who receive Supplemental Security Income (SSI) benefits. 

Beyond covering these mandatory populations, states may expand their Medicaid programs to cover optional populations. 

  • People in the groups listed above whose income exceeds the amount to put them in the mandatory coverage bracket
  • People with disabilities or seniors who do not receive SSI benefits but have an income below the poverty line
  • People classified as “medically needy”: their income exceeds the limits for mandatory coverage, but they experience high medical costs such as nursing home care
  • People whose income exceeds the mandatory limit but require long-term support and services
  • Adults covered under the Affordable Care Act (ACA)

Affordable Care Act

Because of the ACA, adults without disabilities whose income is below 138% of the federal poverty line can enroll in Medicaid programs. A Supreme Court decision in 2012 made this aspect of the ACA optional for states. Texas does not currently offer Medicaid to non-disabled adults.

How To Apply For Medicaid

Qualifying for Medicaid starts with applying for eligibility. In most states, there are two ways to do this. 

The Health Insurance Marketplace

You can fill out an application through the Health Insurance Marketplace. If it appears that you or someone in your household qualifies for Medicaid, Marketplace will pass your information along to your state agency. Texas Health and Human Services will reach out about your enrollment.

The benefit of applying through the Marketplace is that they will also screen your eligibility for other programs. You may find that a Marketplace insurance plan is a cheaper option than the Medicaid program. 

Your State Agency

You can apply for Medicaid directly through your state’s program.  In Texas, you fill out an online form at yourtexasbenefits.com.  The form asks you about which benefits and services you want. You’ll also provide some personal information about the people in your household who need coverage or services. 

After answering the questions on the form, you’ll create an account. Once that’s done, you may log in and fill out the application for benefits. Some answers automatically fill in based on your answers on the first form, but you can change them if you need to. 

Medicaid Vs Medicare

Sometimes confusion arises between Medicaid and Medicare. While both programs are authorized through Title XIX of the Social Security Act, there are some vital differences. Knowing the differences helps you enroll in the program right for you. 

Medicare is a federally funded and administered program to provide healthcare coverage for people over 65 and some individuals with disabilities. Some people are “dually eligible” and enrolled in both programs. As of 2018, about 10 million low-income senior citizens or individuals with disabilities participated in both programs.

At Citra Urgent Care, you can feel good about feeling better. Expect the highest level of compassionate healthcare when you need it most. Proud to serve children and adults across the DFW Metroplex, our dedicated team understands that trust is earned. 

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