Medicaid is a health care assistance program funded by the federal and state governments throughout the country. Through this program, qualified applicants can gain access to free or low-cost medical services. As such, Medicaid eligibility is heavily based on household income, though several other factors are considered as well. The main eligibility groups covered under the program include children and their parents, disabled individuals and seniors. However, some states also extend coverage to individuals who qualify through income alone.
To learn how to apply for Medicaid, applicants must identify the specific program offered in their state. Each state is responsible for its own version, so program names and requirements often vary. Regardless of where an applicant applies, every program is required to cover certain services. Additional coverage is available in certain states as well. Once approved, applicants can continue to get benefits as long as they qualify. With this in mind, understanding the details of this program is an important step in the enrollment process.
What is Medicaid?
Medicaid is a low-cost health insurance assistance program available to certain eligible groups. It is often compared with other government health care options, like the Children’s Health Insurance Program (CHIP) and Medicare. Though all are meant to offer affordable coverage, these programs differ in several key ways. In general, CHIP is a smaller program aimed mostly at children and has income requirements that are less strict, so children may qualify for CHIP coverage even if adults in the same household are not eligible for Medicaid. Unlike Medicare, the CHIP program does not require applicants to pay into it like a traditional health insurance program. Instead, applicants often get services at no cost or for a minimal fee.
Overall, the main aim of this program is to make access to health care more affordable for low-income families and some individuals across the country. Mandatory Medicaid coverage includes a variety of medical services and needs, from check-ups to hospital visits. Interested applicants must submit a Medicaid application to determine if they are eligible.
Who qualifies for Medicaid coverage?
The federal law establishes general Medicaid qualifications that all applicants must meet. Overall, this program seeks to give affordable healthcare coverage to certain low-income groups. In addition to income, eligibility is also determined by age, medical status, household size and family status. Applicants typically covered under this program include:
- Children and their parents or legal guardians.
- Pregnant women.
- Individuals with disabilities.
It is important to note that a Medicaid expansion recently occurred in some states. Under this expansion, participating states allow applicants to qualify using only their income. This means that certain low-income individuals may be eligible to enroll in the program as well. It is important for applicants to understand the policies and income requirements in their state program.
Learn About Medicaid Requirements
Along with the qualifications outlined above, applicants must also meet certain income requirements in order to enroll in Medicaid. Each state establishes specific Medicaid income limits based on the federal poverty level (FPL) and other economic factors. State agencies then use each household’s modified adjusted gross income (MAGI) to calculate income eligibility. These limits can also vary across programs, with many states applying different limits to each eligibility group. An example of common eligibility groups include the following:
- Children between 0 and 1 years of age
- Children between 1 and 5 years of age
- Children between 6 and 18 years of age
- Pregnant women
- Parents of qualifying children
- Adults covered under the expansion
Many states offer an initiative called “Continuous Eligibility” for qualified children. Most public assistance programs require enrollees to report any changes to income that occur, as this affects their eligibility status. However, continuous eligibility allows children to remain qualified even if their household income changes during the Medicaid enrollment year. This initiative was enacted to ensure that children have consistent access to adequate healthcare. Once the enrollment year is over, all families must reapply with their new income information.
When can I apply for Medicaid coverage?
Once you understand the program eligibility requirements, you must decide when to submit your Medicaid application. Most health care plans provide a limited window for applicants to apply for coverage or make policy changes. This is commonly referred to as an open enrollment period, which occurs once every enrollment year. Those who miss the enrollment window must wait until the following year or for a special enrollment period to be triggered in order to apply.
In contrast, there is no Medicaid open enrollment period established in any state. This means applicants can apply and enroll at any time during the year. Those who are deemed qualified begin to get coverage immediately. To speed up the process, applicants should prepare their applications and all of the necessary documents in advance.
What do you need to apply for Medicaid?
In order to complete your Medicaid application, there is certain information you must prepare to share. Applications ask questions about your entire household, including total gross income, citizenship and even medical status. In some cases, you may be required to submit copies of additional documents to verify the claims on your application. In this case, make sure you have access to the following information and documents for each member of your household:
- Proof of citizenship or legal non-citizenship.
- Proof of identity.
- Proof of residence.
- Social Security Number.
- Pay stubs or W-2 forms.
- Policy numbers for any other health insurance your family is enrolled in.
How to Apply for Medicaid
There are two main ways to apply for Medicaid. One popular method is to submit an application to the online Health Insurance Marketplace. When you apply through the Marketplace, your eligibility for other health insurance programs will be determined at the same time. If your eligibility is confirmed, the Marketplace notifies the state agency on your behalf to begin the application process.
You can also learn how to sign up for Medicaid directly through your state agency. Most states offer an online portal for this purpose. You can often apply by mail, fax or in person at an appropriate community customer service center. If you prefer this route, follow these basic steps to apply:
1. Choose one of your agency’s methods of submission.
2. Complete the application.
3. Submit any additional verification documents.
4. Complete a phone interview, if requested by the agency.
Under the Affordable Care Act, many states now offer enrollment help for households that qualify for Medicaid. For example, presumptive Medicaid eligibility is an initiative that allows certain qualified entities to automatically screen and enroll applicants. This helps speed up the application process and allows the program to assist as many households as possible.
What does Medicaid cover?
The Medicaid program is designed to offer coverage for a wide variety of medical needs. Upon approval, applicants get an insurance card that verifies their enrollment. Applicants must present this card at the doctors’ office or medical facility where they are seeking services to access their benefits. According to the law, there are certain services that each state is required to cover. These are known as mandatory benefits and include medical needs such as:
- In-patient and out-patient hospital procedures.
- Checkups and doctor visits.
- Family planning services.
- Lab work and X-rays.
- Preventative screenings.
In addition to these mandatory benefits, each state has the option to cover voluntary services as well. In some states, enrollees can get Medicaid dental coverage, eye care, prescriptions, physical therapy and a wealth of other services.
“How much does Medicaid cost out-of-pocket?” is another important question regarding coverage. Each state is allowed to charge copayments, deductibles and other fees for certain services covered under the program. However, these costs are typically minimal and are largely based on each applicant’s reported income.
When is Medicaid renewal required?
If you are wondering “Do I have to reapply for Medicaid every year?” the answer is no. However, like other public assistance programs, your enrollment in this healthcare option is based on your continuing eligibility. As such, you are required to renew your application each year. During this renewal, you must report changes to your income, household size and any other qualifying factors. In order to avoid a lapse in coverage, it is important to apply for renewal as soon as possible. If you apply past a certain date as outlined by your agency, you will need to reapply.
When it is time to renew your Medicaid application, you will get a notification in the mail from your state agency. This is generally sent 2 months before your enrollment is set to expire. You can also monitor your benefit period through your account in the online portal if one is offered by your state. Most states allow you to renew by completing and returning the notice you received. You may also be eligible to renew online.
What happens if I am denied Medicaid coverage?
There are several reasons why you may get a denial from this health care program. The most common reason for denial is making more than the maximum income limits. In the event that you get a notice denying your benefits, there are additional steps you can take to secure your health care. For example, you may be eligible to enroll in other low-cost healthcare programs, such as CHIP.
Another option is to learn how to appeal a Medicaid claim denial through your state agency. Each state has its own appeal process, including a time limit on when you can file your appeal. If you believe your claim was incorrectly denied, you can call or submit a letter requesting a fair hearing. Depending on where you live, eligibility appeals may also be accepted:
- Through the state’s online portal.
- By fax.
- Through email.
If your request for an appeal is approved, you must attend your assigned hearing date. Fair hearings are generally conducted in person, though it is possible to request a phone hearing instead. During your hearing, a representative from the state Medicaid agency will review your appeal and determine if a mistake was made.