Medicaid

Link to Article: https://www.medicalbillingandcoding.org/medicare-medicaid

Medicaid is a joint state and federal healthcare program that provides care to persons who might not otherwise be able to afford it. Medicaid provides coverage to low-income families and individuals, disabled individuals, and certain elderly persons.

Unlike Medicare, which is a federal program with universal standards, Medicaid regulations and restrictions vary by state. Each state has to maintain its own Medicaid program (like Indiana’s HoosierCare or Wisconsin’s BadgerCare). Each of these state-based Medicaid programs still has to meet certain standards established by the federal government, but you should expect to see a wider range of variation in Medicaid policies than Medicare policies.

Since some states’ Medicaid coverage is more extensive than others, let’s focus only on the minimum requirements for the program, as laid out by the CMS and the federal government. Below you’ll find seven of the basic services covered by Medicaid.

  • Family planning care
  • Prescription drug costs
  • Inpatient/outpatient hospital services
  • Pediatric services
  • Mental health care
  • Occupational, speech, and physical therapy
  • Dental healthcare and related service

Like the services provided by Medicaid, a person’s eligibility for Medicaid may vary by state. Still, there are some relatively common baseline criteria for coverage, including:

  • Adults with children earning less than a certain income level (varies by state and number of children)
  • Individuals earning up to 133% of the poverty line (this provision is part of the Affordable Care Act, and will go into effect in January of 2014)
    • Individuals who earn slightly more than the minimum threshold, you may still qualify for Medicaid if they pay an additional premium
  • Individuals suffering from chronic disabilities
  • Individuals who receive Social Security benefits may also qualify for Medicaid

These are not hard and fast criteria for enrollment. Medicaid accepts subscribers on a categorical level. That is, their income is not the sole determining factor of their eligibility. Instead, a patient’s eligibility depends on how they fit into a certain category, which might include pregnant or nursing mothers, poverty-stricken individuals, or disabled persons.

Like Medicare, Medicaid acts as a third-party payer that reimburses providers for the health services they perform. Unlike Medicare, a majority of Medicaid subscribers are enrolled in some sort of managed care program through Medicaid. Under this program, subscribers must pay a monthly premium. Poorer elderly individuals are more likely to use the basic fee-for-service Medicaid program, while younger Medicaid recipients are more likely to use the managed care option.