Understanding Medicaid

by Tyler Abbott on February 27, 2024

Medicaid is a key component of the healthcare system in the United States, providing health coverage to millions of low-income individuals. Established in 1965 under Title XIX of the Social Security Act, Medicaid is a means-tested entitlement program jointly funded by state and federal governments. Over the decades, Medicaid has grown to become the largest health insurance program in the country, covering over 70 million Americans. To understand Medicaid and its vital role, it is important to examine its definition and eligibility requirements, how it varies by state, the process to apply for coverage, what services it covers, reimbursement rates, its economic and public health impact, and recent policy changes that shape its future.

Definition of Medicaid

Medicaid is a public health insurance program that provides health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is means-tested, meaning eligibility is based on income and asset limits. Importantly, Medicaid is not the same as Medicare – Medicare is a federal health insurance program primarily for seniors 65+ and certain younger disabled individuals, while Medicaid eligibility is based on financial need. However, some low-income seniors may qualify for both Medicare and Medicaid coverage.

The key difference is that the federal government funds Medicare, while both state and federal governments jointly fund Medicaid. Each state administers its own Medicaid program within federal guidelines. As such, states have flexibility in determining exact eligibility limits and benefits packages, leading to some variation in Medicaid programs across different states. However, all state Medicaid programs have mandatory minimum federal requirements in terms of who qualifies and what basic benefits must be covered.

Eligibility for Medicaid

In all states, Medicaid has mandatory income thresholds based on the Federal Poverty Level (FPL) that determine eligibility. Certain groups have higher income thresholds and qualify more easily. These include children, pregnant women, elderly and disabled individuals. Non-elderly, non-disabled adults historically had the strictest limits, but the Affordable Care Act expanded eligibility in many states up to 138% FPL for this group.

When applying for Medicaid, applicants must provide documentation to verify identity, citizenship status, state residency, and income eligibility. The exact documents needed vary but commonly include an ID card/driver’s license, birth certificate, pay stubs, and tax returns. Providing complete and accurate eligibility documentation is crucial for successful enrollment. Groups like pregnant women, children, and disabled individuals have easier pathways to qualify within defined limits.

Medicaid by State

Federal vs State Control of Medicaid

Medicaid is a jointly funded state-federal program. The federal Centers for Medicare and Medicaid Services (CMS) provides oversight and issues mandatory regulations that state Medicaid programs must follow related to eligibility, benefits, and more. Within federal rules, states have the flexibility to adapt their programs – by expanding coverage beyond federal minimums, adjusting exact income limits, or offering additional optional benefits.

Consequently, Medicaid can vary significantly between states in terms of specific income limits for eligibility, the range of benefits covered, and reimbursement rates for providers. Some states may have expanded eligibility rules and more generous benefits than federally mandated, while others may follow only the federal minimums. These state decisions on operating Medicaid impact how coverage reaches low-income residents.

Varying State Rates

For example, New York State has more expansive Medicaid eligibility reflecting its high cost of living – adults without children qualify up to 138% of the poverty line. The state also offers extensive optional benefits like dental, vision, and home care services. This wider coverage allows more low-income working adults to obtain health insurance through Medicaid.

Meanwhile, Texas follows the federal minimums for Medicaid eligibility and benefits. It has stricter income thresholds for adults without dependents and does not offer several optional services covered by New York. Lower Medicaid enrollment in Texas leaves many poor adults uninsured. Different approaches to Medicaid in New York and Texas illustrate state flexibility within federal regulations.

How to Apply for Medicaid

Applying for Medicaid coverage involves gathering key documents, completing the full application, and managing the enrollment process. Following guidelines carefully is important, as incorrect or incomplete applications can cause delays or denials of coverage.

Required documentation includes proof of identity, immigration status, state residency, and income eligibility. Specific documents needed are:

  • Identification card/driver’s license
  • Birth certificate or U.S. passport
  • Pay stubs, tax returns, bank statements
  • Social Security card
  • Proof of address like utility bills

Having these documents ready saves time and speeds up application processing to get coverage faster.

Medicaid applications require accurately reporting a household’s total income. This determines whether income falls within that state’s eligibility thresholds. Applicants must include income sources like salaries, unemployment insurance, social security payments, and pensions. Precisely calculating income avoids having coverage denied or discontinued later due to discrepancies.

Completing applications involves detailing all household members seeking coverage. Their ages and relationships must be listed to assess eligibility. Any changes in family circumstances or contact information should be immediately reported to update records accordingly. Keeping application data current is vital.

Medicaid Application Process

Applying for Medicaid coverage can occur online, by phone, in person, and through other avenues depending on the state.

  • Online: Most states now offer Medicaid applications on their official websites. Online application forms are convenient but individuals without reliable internet access can use other methods.
  • By phone: Calling a state or county Medicaid office allows completing applications over the phone with a representative. Help filling out forms accurately is available.
  • In-person: Visiting local Medicaid offices, community health centers, and hospitals enables getting in-person assistance from trained navigators to apply. Some states also station representatives at other government offices.
  • Alternative options: Many states permit submitting paper applications by mail or fax. Application downloads, drop boxes, and emailed forms offer additional pathways to apply.

After successful submission, Medicaid applications face a review process to confirm eligibility and make enrollment determinations. If approved, applicants select or are assigned a health plan to begin using coverage; they receive cards proving active enrollment. From initial application through activation of benefits, this Medicaid process enables access to healthcare.

Services Covered by Medicaid

Medicaid programs cover a wide range of health services, with some being mandatory offerings under federal law while others are optionally added by states. Understanding covered benefits is key to maximizing Medicaid insurance.

Mandatory Services

The federal government requires all state Medicaid plans to cover certain basic services. These include:

  • Inpatient and outpatient hospital services
  • Prenatal care, deliveries, and postpartum care
  • Laboratory and X-ray services
  • Pediatric care including immunizations and check-ups
  • Family planning services
  • Rural health clinic services
  • Emergency ambulance transportation
  • Mental health and substance abuse treatment

Covering these mandatory services ensures Medicaid recipients nationwide can access essential care like hospital visits and pregnancy-related care. States cannot limit or exclude recipients from these benefits.

Optional Services

States can choose to cover additional “optional” Medicaid benefits based on budget availability and policy priorities. These include:

  • Prescription drug coverage
  • Dental and vision care
  • Physical therapy
  • Home healthcare
  • Hospice care
  • Respiratory equipment

Currently, all states offer prescription drugs as an optional benefit given their importance. Other optional benefits that improve quality of life and health outcomes are not universally available. State decisions on covering optional Medicaid services impact what additional care low-income residents can access.

How Much Does Medicaid Pay?

Medicaid plays a major role in financing healthcare through payments to hospitals, clinics, and providers serving beneficiaries. However, Medicaid reimbursement rates vary by state.

Some analyses indicate Medicaid reimbursements may only cover roughly 2/3rds of the actual costs to deliver care. Critics argue that these lower rates contribute to providers, limiting how many Medicaid patients they accept. This limited acceptance rate would of course impact health care accessibility.

A Medicaid recipient will see a significant decrease in direct out-of-pocket health expenses. Beneficiaries have no deductibles and minimal copays that are based on income level – nominal fees range from $0.65 to $8 on most services. For patients living in or near poverty with no other insurance options, Medicaid constitutes a financial lifeline amid costly medical bills.

The federal government matches state funding for Medicaid based on a formula, with poorer states receiving more generous federal match rates. For states weighing Medicaid expansion under the ACA, this additional federal money serves as an incentive by substantially cutting state costs to cover more low-income adults. The 19 non-expansion states still leave billions in federal subsidies untapped by declining expansion.

The Impact of Medicaid

Medicaid and the Economy

With over $600 billion in annual expenditures, Medicaid payments constitute a major economic force directly sustaining healthcare jobs and indirectly supporting wider state economies.

  • Medicaid is the largest financial program covering long-term care services, financing over 60% of all nursing home beds—a vital healthcare sector employing over 1 million nationally.
  • Similarly, Medicaid funds nearly half of all births, driving demand for obstetricians, nurses, and other related jobs. The program’s payments sustain the equivalent of 2.3 million full-time healthcare jobs.
  • A 2016 study found Medicaid expansion boosted states’ economic output and activity. States choosing expansion saw healthcare sectors grow while non-expansion states lagged – impacting health jobs, tax revenue, and local economies.

Medicaid and Public Health

Research indicates that Medicaid coverage significantly increases access to care and utilization of preventive health services for millions of Americans.

  • Medicaid enrollment drops uninsurance rates and reduces reliance on costly emergency room visits for primary care. The uninsured are much less likely to have a regular source of care or receive screenings.
  • Studies associate earlier Medicaid expansion under the ACA with reductions in infant and maternal mortality along with other positive population health outcomes. This suggests expanded coverage improves access at the critical perinatal stage.
  • Medicaid access also appears to reduce racial disparities in healthcare utilization and health outcomes between white and minority patients – a key priority as communities of color disproportionately comprise Medicaid eligibility groups.

Overall, Medicaid exerts an overwhelmingly positive public health impact by facilitating health promoting behaviors like preventive primary and prenatal care to drive down mortality and mitigate health disparities.

Recent Changes and Future of Medicaid

Potential Future Changes

As a major government program, Medicaid is subject to frequent policy debates that could reshape its future. Under Trump, Congressional Republicans unsuccessfully attempted to repeal the ACA’s Medicaid expansion and impose federal spending caps on Medicaid funding. However, the American Rescue Plan Act signed by Biden temporarily increased subsidies and incentives for the 12 remaining non-expansion states to close coverage gaps.

With Medicaid poised to keep expanding post-pandemic, ideological battles around the program’s scope and sustainability will likely persist. Any major changes would require bipartisan commitment absent currently. Most urgently, temporary COVID relief increasing federal Medicaid funds will expire shortly, forcing states to reckon with financing decisions in coming years.

The Ongoing Role of Medicaid

Medicaid will continue serving as the nation’s main health coverage program for low-income populations. Enrollment is projected to keep rising as economic fallout from COVID-19 pushes more Americans into financially vulnerable situations meeting Medicaid thresholds.

This increased coverage addresses near-term medical needs but also has value as a preventive investment in population health outcomes. As shifts in the economy, demographics, and policy reshape eligibility, Medicaid’s flexible design as an open-ended entitlement will remain crucial to catch those who would otherwise slip through holes in the healthcare system.

Ultimately, Medicaid reflects American social contracts around shared responsibility for healthcare access across income levels. Its evolution and adaptability over 50+ years confirm Medicaid’s vital role is here to stay as a pillar of American social welfare policy.