Medicaid Coverage Basics

What is Medicaid?

Medicaid is a joint federal-state program that provides health coverage to low-income individuals and families. It's the largest source of health coverage in the United States.

Eligibility Basics

Who May Qualify

Medicaid is available to:

• Low-income adults (in expansion states)
• Children in low-income families
• Pregnant women
• Elderly individuals
• People with disabilities
• Some parents and caretakers

Income Requirements

Income limits vary by:

• State
• Family size
• Category of eligibility
• Whether state expanded Medicaid

Expansion States

States that expanded Medicaid (as of 2024):

• Cover adults up to 138% of federal poverty level
• About $20,120/year for individual (2024)
• About $41,400/year for family of four

Non-Expansion States

Some states haven't expanded Medicaid:

• More limited eligibility
• May require very low income
• May not cover adults without children

Other Requirements

• U.S. citizenship or qualified immigrant status
• State residency
• Some states have asset limits

What Medicaid Covers

Mandatory Benefits

All states must cover:

• Inpatient hospital services
• Outpatient hospital services
• Physician services
• Laboratory and X-ray services
• Nursing facility services
• Home health services
• Family planning services
• Rural health clinic services
• Federally qualified health center services
• Pediatric and family nurse practitioner services
• Nurse-midwife services
• Early and periodic screening, diagnostic, and treatment (EPSDT) for children

Optional Benefits

States may also cover:

• Prescription drugs
• Physical therapy
• Dental services
• Vision services
• Mental health services
• Personal care services
• Hospice care
• Case management

Check Your State

Benefits vary significantly:

• Visit your state Medicaid website
• Call the Medicaid hotline
• Ask about specific services

Cost-Sharing

Generally Low or No Cost

Medicaid typically has:

• No or low premiums
• No or low deductibles
• Minimal copays

Copay Limits

• Often $1-4 for most services
• Emergency room may have higher copay if non-emergency
• Inpatient stays may have small copay
• Exempt groups (children, pregnant women) often no copays

What Can't Be Charged

Providers cannot:

• Deny services for inability to pay copay
• Balance bill Medicaid recipients
• Charge more than Medicaid allows

State Variations

Why It Varies

• Medicaid is a federal-state partnership
• States have flexibility in administration
• Different optional benefits chosen
• Different income limits applied

Examples of Variation

Aspect	Example Variation
Eligibility	Expansion vs. non-expansion
Benefits	Dental coverage varies widely
Provider networks	Managed care vs. fee-for-service
Premiums	Some states charge low premiums

Finding Your State's Rules

• Healthcare.gov (Medicaid information by state)
• State Medicaid agency website
• Local benefits office
• Community health centers

Managed Care vs Fee-for-Service

Managed Care

Most states use managed care:

• You join a health plan
• Plan manages your care
• Must use plan's network
• Plan receives per-member payment

Fee-for-Service

Some states or populations use traditional Medicaid:

• See any Medicaid-accepting provider
• Claims paid individually
• More provider choice
• Less care coordination

Common Issues

Finding Providers

• Not all providers accept Medicaid
• Use your state's provider directory
• Community health centers often accept Medicaid
• Ask if provider accepts your specific plan

Prior Authorization

Medicaid often requires pre-approval for:

• Certain medications
• Specialty services
• Durable medical equipment
• Some procedures

Maintaining Coverage

• Report changes (income, address, family size)
• Renew when required (usually annually)
• Respond to requests for information
• Don't assume continued coverage

Medicaid and Other Insurance

Medicaid as Secondary

If you have other insurance:

• Other insurance pays first
• Medicaid may cover remaining costs
• Must report other coverage

Medicaid and Medicare (Dual Eligible)

If you qualify for both:

• Medicare is primary for most services
• Medicaid may help with Medicare costs
• May qualify for Medicare Savings Programs
• Special needs plans available

Getting Help

Applying for Medicaid

• Through Healthcare.gov in most states
• State Medicaid office
• In person at benefits office
• Community organizations that assist with applications

If You Have Problems

• Contact your managed care plan
• State Medicaid agency
• Ombudsman programs
• Legal aid organizations

Medicaid provides essential coverage for millions. Understanding your benefits helps you access the care you need.