Medicaid is one of the most extensive social welfare programs in the United States, providing health care coverage to more than 80 million people nationwide. It’s a needs-based program, meaning that only low-income people are eligible for coverage. Each state manages its own Medicaid program to determine the type, duration, amount, and scope of health services within the larger federal guidelines. Medicaid eligibility qualifications vary by state, but most are based on your:
Household incomeFamily size and statusDisability status
In states with expanded Medicaid programs, you qualify based only on your income. For example, if you live in a state with expanded Medicaid and your income is below 133% of the federal poverty level, you’ll likely qualify for coverage. When you apply for Medicaid, you’ll be required to provide proof of your income and copies of legal documents such as your birth certificate and Social Security card. Requirements may vary from state to state.
Example of Medicaid Works
For example, let’s say you apply for coverage in Georgia. You’ll complete the application through the state’s website or apply by phone, mail, or in person. As a part of the application process, you’ll submit any required paperwork. A Medicaid specialist then reviews your application and decides your eligibility. If you’re approved for coverage, you’ll get your Medicaid card in the mail and can begin receiving care. Many states will enroll you in a privately managed care plan, through which you’ll have an assigned primary care provider (PCP) and must get a referral if you need specialist care. If you’re not enrolled in a managed care plan, your Medicaid will work on a fee-for-service (FFS) system. In this model, the state pays providers directly for your covered service instead of paying a fee to your managed care plan.
Medicaid vs. Medicare
Medicare is designed to assist older U.S. citizens and qualified immigrants. In most cases, you must be at least 65 years old to qualify for Medicare coverage, although certain younger people may be eligible based on their disability status. In contrast, Medicaid provides coverage for U.S. citizens and qualified non-citizens of all ages, as long as they meet the eligibility guidelines. Another key difference is the amount of money you’ll have to pay out of pocket. With Medicare, you’ll be responsible for copays, coinsurance, and deductibles. However, Medicaid participants often don’t have to pay anything. If there are fees, they’re kept to a nominal level. Since Medicare is run at the federal level, it works the same, no matter where you live. Medicaid is managed by the federal and state governments, which means eligibility and coverage vary by state. In addition, you can only apply for Medicare at certain times, beginning with your initial enrollment period. There are no limitations on when you can apply for Medicaid coverage.
What Does Medicaid Cover?
Medicaid coverage varies from state to state. However, all states must provide certain mandatory items, such as:
Inpatient and outpatient hospital careDoctor visitsFamily-planning servicesLaboratory and X-ray servicesHome health servicesTransportation to medical appointments
States may decide to cover optional services such as:
Dental careVision carePrescription drugsChiropractic servicesHospice careRehabilitative services
Medicaid expansion for adults covers the 10 essential health services defined by the Affordable Care Act. Long-term care and home and community-based services (HCBS) are also covered. These programs help patients stay active and independent in their homes and communities. Want to read more content like this? Sign up for The Balance’s newsletter for daily insights, analysis, and financial tips, all delivered straight to your inbox every morning!
