New to Medicaid? How It Works

Medicaid is government-funded health insurance for people with lower incomes. Nearly 60 million Americans use it. Medicaid can help if you:

  • Don't make much money or are on a limited budget
  • Can't work because of a disability
  • Are already enrolled in Medicare but can’t afford the payments
  • Are pregnant and don't make much money

The federal government requires that Medicaid cover certain groups of people -- like people with low incomes. The government sets the minimum benefits, too.

Your state also has a lot of say in the specifics of who gets covered. Generally, children, pregnant women, and people who are disabled get the most generous coverage.

What Types of Health Care Does Medicaid Cover?

There are 56 different Medicaid programs -- one for each state, the District of Columbia, and the U.S. territories. Each Medicaid program may help pay for different types of health care. What you pay varies, too. Any type of care it helps pay for is considered "covered."

You can use Medicaid for many types of health care. Medicaid covers screening and diagnostic tests, including X-rays. It helps pay for hospital stays and doctor visits. Prescription drugs are sometimes covered and so is family planning. It also covers nursing home and long-term care services for people with lower incomes.

If you have a child who qualifies, Medicaid covers even more. You may get financial help if your child needs to see an eye doctor or needs glasses. Mental health services are covered. So is long-term care in your home if your child needs it.

You can get financial help if your spouse needs to be in a nursing home. Long-term care is costly. Medicaid can help make sure you have enough money to stay in your home while your spouse gets care elsewhere.

Who Is Eligible for Medicaid?

The rules about who can use Medicaid depend on the state you live in. Federal law requires that states cover certain population groups. States then have the option of expanding coverage to other groups or making the coverage more generous.

For instance, in some states, if you're disabled, you can use Medicaid no matter how much money you make. In other states, if you’re disabled, you may not be eligible for Medicaid coverage if your income is above a certain level.

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Your income is important when applying for Medicaid. States usually have a cut-off based on your income and assets. If you're below a certain level, you may qualify.

You might be eligible even if you earn more. Even if your income and assets are above the cut-off level, you might still get Medicaid if your medical bills are high. You may be able to subtract those expenses from your income. This is called the spend-down process. After you subtract costs like hospital care and doctor visits, your income will be lower and may make you eligible for Medicaid.

You may be able to start using Medicaid. The Affordable Care Act is helping states make Medicaid available to more people.

The idea is to open up Medicaid to people who have low incomes and can't afford insurance on their own but who made too much to qualify for Medicaid in the past.

However, states can decide whether they will expand Medicaid to include more people. Some have. Some haven't. See your state page to find out if your state is expanding Medicaid.

States that have decided to expand Medicaid must provide coverage to everyone with incomes below 138% of the federal poverty level. That's:

  • $16,394 or less a year if you're single
  • $33,534 or less a year for a family of four

If you live in Alaska or Hawaii, you can make more money and still qualify.

Whether you're a U.S. citizen can make a difference. Each state has rules about citizenship. For instance, some states won't let you get Medicaid if you're not a citizen. Other states allow all immigrant children and pregnant women to use Medicaid.

Applying to Medicaid

If you want to apply to Medicaid, you should also know that:

Once you're approved, you'll get a Medicaid card. This is your ID card. You'll need to show it to get any Medicaid benefit, such as a doctor's visit or a prescription.

At the beginning, your Medicaid coverage is retroactive. That means it covers your expenses for up to 3 months before you applied, if you were Medicaid-eligible at the time.

 

WebMD Medical Reference Reviewed by Sarah Goodell on September 16, 2016

Sources

SOURCES:

Centers for Medicare & Medicaid Services: "Need Health Insurance?;" "Eligibility;" "Spousal Impoverishment;" "Non-Disabled Adults;" "Children;" "Individuals With Disabilities;" and "Pregnant Women."

Medicaid.gov.

Department of Health and Human Services: "Medicaid: Getting Started;" "Overview of Immigrants' Eligibility for SNAP, TANF, Medicaid, and CHIP;" "Medicaid;" "2013 Poverty Guidelines;" "Eligibility;" and "What does Medicaid cover?"

Florida Department of Children and Families: "Medicaid."

Kaiser Family Foundation: "Medicaid: A Primer" and "The Medicaid Program at a Glance."

Michigan Department of Community Health: "The mihealth card."

New York Department of Health: "Medicaid in New York State" and "Medicaid Application form."

North Carolina Division of Medical Assistance: "How to Apply for Medicaid."

Social Security Administration: "Apply for Medicaid."

Texas Health and Human Services Commission: "Your Texas Benefits Medicaid Card Questions and Answers."

Virginia Department of Social Services: "Applications by Category" and "Application for Benefits."

Healthcare.gov. 

Coverageforall.org.

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