Do you find yourself wondering whether or not you, or a loved one, is eligible for Medicaid? What does Medicaid cover, exactly?
In this Guide to Medicaid, we will go over exactly what Medicaid is, the differences between Medicaid and Medicare, what Medicaid will cover, and who qualifies for Medicaid.
Let’s get started!
What is Medicaid?
Medicaid is a government program, specifically designed to deliver health insurance to individuals with low income and few, or no, assets. Many people confuse Medicaid with Medicare, due to the fact that they have similar-sounding titles. However, they have entirely different eligibility benefits and requirements, as they serve different purposes.
What is the difference between Medicaid and Medicare?
Medicare is much easier to qualify for, almost anyone over the age of 65 will qualify for it. On the other hand, Medicaid is only available to people who are over 65 years old, are blind or have a serious disability, and/or people who meet the income and resource limits.
If your parents don’t have an extremely low-income and do have some assets, they may still be eligible for Medicaid, especially if they have high medical costs. That said, it is important to become familiar with the program. This is particularly true if either, or both, seniors need long-term care – which Medicaid can cover even if the senior(s) own their home.
What you need to know about Medicaid:
Federally-supported, but state-administered, Medicaid is a program intended to provide health insurance to low-income, low-asset families and individuals. This includes people with certain disabilities and/or people over 65 years of age.
Who qualifies for Medicaid?
All Medicaid plans are required to provide coverage to people who have limited income and resources, and are over the age of 65. In addition, people who are blind or disabled and have low income and few assets. Considering those factors, Medicaid eligibility guidelines vary from state to state. There are some portions of your income which would not be counted when determining Medicaid eligibility, these include your car and home. To find the specific Medicaid requirements for your state online, visit the Medicaid/Medicare section of GovBenefits.gov.
It is important to realize that even if the senior(s) applying currently make more money that Medicaid income limits allow, they may still qualify if they have a substantial amount of medical bills. The reason is because most state Medicaid programs will subtract applicants’ medical bills from their residual income when determining eligibility. Once again, the details of these calculations, also known as “Medicaid spend-down” rules, vary from state to state.
If one of the seniors lives in a nursing facility while the other one lives at home, there may be more lenient income and asset rules to consider.
Can you use both Medicare and Medicaid at the same time?
In short, yes.
There are certain items and/or services that Medicaid may cover, but Medicare won’t. These include items like eyeglasses, hearing aids, and/or dental care. Medicaid can also cover Medicare premiums, copayments, and deductibles, should you meet eligibility requirements.
What does Medicaid cover?
If you qualify for Medicaid benefits, you’ll receive coverage on a variety of medical expenses. Some of these include:
- Outpatient care
- Ambulatory services
- Lab testing
- Nursing facility services
- Dental care
- Home health services
- Part-time in-home nursing care
- Certain medical supplies
Prescription drugs are covered through the Medicare prescription drug benefit. Though Medicaid may pay your Part D plan premiums and copayments, and also cover certain drugs that are not covered by the Part D plan.
One of the most significant benefits of Medicaid for many people, is that is will cover long-term custodial care within a nursing facility, as well as long term in-home care. Neither of which would be covered by Medicare.
Which doctors can we see?
To know for sure, you will have to check yourself.
Medicaid does not pay out money directly to you; instead, it sends payments directly to your healthcare provider(s). However, due to the fact that Medicaid reimbursement rates are low, some doctors don’t accept Medicaid patients. It is vitally important to determine whether the doctors you want to see will actually accept Medicaid patients before you make an appointment to see them.
What won’t be covered by Medicaid?
As we mentioned before, Medicaid eligibility requirements vary from state to state. In similar fashion, the list of what is and is not covered by Medicaid also varies from state to state.
Generally speaking, Medicaid won’t cover any elective procedures or cosmetic surgeries, medical procedures related to obesity (gastric bypass surgery, for example), or prescription drugs for individuals who are enrolled in Medicare. You may have to pay a small portion of the cost (a co-payment) for some medical services that Medicaid does cover, depending on your state’s rules.
What if my income is too high to qualify for Medicaid?
If you don’t meet the income eligibility requirements, it’s still possible to qualify for some Medicaid benefits.
For example, a specific Medicaid program (known as the Specified Low-Income Medicare Beneficiary Program, or SLMB) will pay monthly Medicare Part B premiums, and has higher monthly income limits than most states’ basic Medicaid income limitations. In addition, if you are blind or disables, the income eligibility limits for you may be higher than for individuals who qualify based off of their age alone.
Medicaid spend-down: How does Medicaid spend-down work?
If your assets alone would qualify you for Medicaid, but your income is over your specific state’s Medicaid income limit, you may still be able to qualify for Medicaid coverage if your medical bills add up to more than the amount by which your income exceeds the Medicaid limit.
“Share of cost” is the Medicaid jargon for this spend-down provision. It is similar to a deductible under a typical health insurance policy, because it is the amount you have to pay out-of-pocket before any Medicaid coverage will kick in.
Are there specific types of senior communities I’ll be able to enter under Medicaid coverage?
There are some skilled nursing or assisted living communities that accept residents who are on Medicaid. However, those communities typically have a certain percentage of their total beds that can be occupied by Medicaid residents. To find out whether or not an assisted living community will accept patients on Medicaid, you will have to call them directly and ask. There are some communities that will make payment arrangements, stating that if you can pay privately for 6 months to one year, they will assist you in converting your payments to Medicaid moving forward.
As a Medicaid-eligible resident, you must prove that you have an income equal to, or greater than, the current Supplemental Security Income and must contribute all but $90 each month to the provider for lodging, meals and additional services. The $90 you get to keep is like a personal allowance, to be used as you wish. If your current income is enough to pay the assisted living community rates privately, you may do a spend-down and continue to pay privately until you reach the qualifying Medicaid limits. At that time, the community will usually assist you in converting your private payments into Medicaid covered ones.
Do I qualify for Medicaid? How to apply for Medicaid benefits:
Have you applied for Medicaid in the past?
Even if you’ve previously been told that you don’t qualify for Medicaid, you may qualify under the new rules. You can see if you are eligible for Medicaid Benefits 2 ways:
- Visit your state’s official Medicaid website. From there, you will be able to fill out an application to see if you are eligible. If you qualify, coverage benefits can activate immediately.
- Go to the Health Insurance Marketplace and fill out an application. Once you finish, you will be able to see which programs you and your family are eligible for.