Those who fall into one of the following categories are eligible for Medicaid benefits:
People whose salary falls within a certain range
Minors who are in need of foster care or sponsored adoption
Former foster youth up to the age of 26 may be eligible for certain services.
Kids in wheelchairs (birth to 19)
Expectant mothers
Those who have been diagnosed with breast or cervical cancer
Labourers with Disabilities
Other visually impaired and handicapped people
Poor Medicare recipients (Medicare Savings Programs)
Most minors under the age of 19 are automatically and permanently qualified for Medicaid. Meaning that if they are deemed eligible, they will remain so for up to a year regardless of any changes in their situation. Similarly, once a woman becomes eligible because she is pregnant, she typically keeps that eligibility throughout her pregnancy and for at least 60 days after it ends. Medical assistance from Medicaid might start up to three months before the month of application. To the tune of over 72.5 million Americans, including children, pregnant women, parents, retirees, and those with disabilities, health care is provided through Medicaid, a federal and state programme.
When it comes to health insurance in the United States, Medicaid is by far the most common option. Under federal law, states must provide Medicaid coverage to a designated population in order to take part in the programme. Examples of required eligibility categories are low-income families, pregnant women and children who meet certain criteria, and those who receive Supplemental Security Income (SSI). Individuals receiving home and community-based assistance, as well as children in foster care who are not otherwise eligible, are two examples of categories that states may elect to cover if they so desire.
Low-income Americans under the age of 65 can now be covered by Medicaid according to the Affordable Care Act of 2010. All states were required to cover children with incomes at or below 133% of the federal poverty level (FPL), however, most states cover children with incomes at or above greater levels, and states were given the option to cover adults with incomes at or below 133% of the FPL. The majority of states have already decided to extend Medicaid to cover more people, and those that haven’t can change their minds at any time. Check to see if low-income individuals are covered by Medicaid in your state.
Financial Eligibility Criteria for Medicaid Participation
Income eligibility for Medicaid is now calculated using the Modified Adjusted Gross Income formula, which was introduced by the Affordable Care Act (MAGI). Your eligibility for health insurance subsidies and government programmes like Medicaid and CHIP are calculated using your Modified Adjusted Gross Income (MAGI). The Affordable Care Act simplified the application and enrollment processes for many government healthcare programmes by standardising eligibility criteria and income thresholds. Most children, pregnant women, parents, and adults have their Medicaid eligibility determined by their Modified Adjusted Gross Income (MAGI). To calculate Medicaid eligibility, the MAGI approach takes into account both taxable income and tax filing status. Medicaid eligibility was formerly determined using formulas from the defunct Aid to Families with Dependent Children programme; this was changed to the MAGI system in 1998.
The MAGI-based technique does not permit an asset or resource test or income disregards that differ by state or eligibility category. Those who qualify on the basis of age, blindness, or handicap are not subject to the MAGI-based income counting criteria (65 and older). Some states, known as 209(b) states, utilise some more restricted eligibility criteria than SSI, but mostly follow SSI techniques for determining Medicaid eligibility for those aged 65 and up, or those who are blind or disabled. Those who are eligible for both Medicare and Medicaid (often referred to as “dual eligibles”) have their Medicare premiums, deductibles, and/or coinsurance paid for by Medicaid under the Medicare Savings Programs. When determining Medicaid eligibility, the federal government does not consider income for some populations. Eligibility for this coverage may depend on participation in another programme, such as Supplemental Security Income or the Breast and Cervical Cancer Treatment and Prevention Program. Adopted children who have an active adoption assistance agreement under Title IV-E of the Social Security Act are automatically enrolled. Regardless of their family’s financial level, young adults who satisfy the criteria for qualifying as former foster care recipients are welcome to apply.
Financial Ineligibility
People need to complete additional, non-financial requirements to qualify for Medicaid. To qualify for Medicaid, an individual must normally reside in the state offering the programme. They must be a citizen or lawful permanent residents of the United States. Other factors, such as age, pregnancy, and parenthood status, might put some people outside of the eligible range.
Initial Date of Coverage
An individual’s Medicaid coverage might begin on the day they apply or the first of the month they apply for benefits, depending on which comes first. It is possible to get benefits retrospectively for up to three months previous to the month of application if the individual would have been eligible at that time had they applied. If you no longer fulfil the criteria for eligibility, your coverage will likely expire at the end of the current month.
Requiring Medical Attention
Individuals whose income is too high to qualify for Medicaid under other criteria categories may be eligible for a state’s “medically needy programme.” People who make more money than their state’s medically needy income threshold might still qualify if they spend down to that level. Without health insurance, people reduce their budgets by paying out of pocket for necessary medical and corrective services. A person is eligible for Medicaid if their out-of-pocket medical costs have reached the “spend down” amount, which is the difference between their income and the state’s medically needy income threshold. The Medicaid programme will foot the bill for any services above and above what was spent on the individual’s application.
Even if the state already has a medically needy programme, 209(b) states are required to enable a spend-down to the income qualifying thresholds for groups based on blindness, handicap, or age (65 and older). Medically needy or 209(b) spend-down programmes are in place in 36 states and the District of Columbia.
Appeals
If a person is denied anything, or if a state agency takes an action that person feels was wrong, or if the state agency does not respond promptly enough, that person has the right to a fair hearing. There is flexibility in how different states organise their appeals procedures. Medicaid agencies may handle appeals themselves or assign them to the Exchange or the Exchange Appeals Entity (for appeals of denials of eligibility for individuals whose income is determined based on MAGI). If a state meets the requirements of the Intergovernmental Cooperation Act of 1968, CMS will allow the delegation of appeals to another state agency.