Medicaid, a federal and state public health program, covers millions of Americans who would otherwise struggle to find and pay for health insurance. The main focus of Medicaid is to provide coverage for low-income individuals, but there are some exceptions, including disabled adults and children. Eligibility for Medicaid is based on an income calculation but also on several other factors which can be set by each individual state if minimum federal requirements are met.

States may also choose what to cover beyond the minimum benefit requirements set by the federal government. Many services are covered by Medicaid, more than are covered by Medicare, the health program for seniors. Access to care and quality of care are consistently found to be good for patients on Medicaid, especially when compared to the uninsured.

What is Medicaid?

Medicaid is a public health insurance program that is jointly funded by the federal government and state governments. It provides health care coverage mostly for low-income people, but other people are eligible based on certain factors, such as disabilities. Although the program is jointly funded, it is administered separately in each state. This means that rules for eligibility, coverage, cost, and other factors vary by state. People covered by and enrolled in state Medicaid plans get free or low-cost healthcare.

Over 70 million people in the U.S. are covered by Medicaid or the Children’s Health Insurance Program, CHIP, which covers many children in low-income families that don’t qualify for Medicaid. Medicaid coverage is extensive and includes more than one-third of all children in the U.S. and nearly half of all births. About two-thirds of residents in nursing homes are covered by Medicaid. Medicaid is often confused with Medicare, which is a program that covers people over the age of 65, regardless of income. In 2016, Medicaid cost $553 billion. About $349 billion of that cost was covered by the federal government, and the rest came from the states.

Who is Eligible for Medicaid?

The main purpose of Medicaid is to provide healthcare coverage for people with low incomes. The federal government sets minimum standards for eligibility, but states can set higher standards. There are categories of eligibility, including children in low-income families, parents of those children, pregnant women, and seniors with low incomes.

Another category of eligibility for Medicaid is people with disabilities. Those people with disabilities who cannot or have not ever worked are enrolled in Medicaid, even if they receive supplemental security income (SSI), and independent of income. Whether or not someone who is disabled, who receives SSI, and who works can be eligible for Medicaid depends on a state’s rules.

In 2010, when the Affordable Care Act passed, states were given the ability to expand Medicaid coverage to any low-income person under the age of 65, regardless of the eligibility categories. It also introduced a new way to calculate income-based eligibility for Medicaid that was designed to streamline the process. Certain people are exempt from that calculation, including blind and disabled people. Some states also have a program for the “medically needy.” These are people who have serious medical needs with expensive costs and who would not otherwise be eligible for Medicaid coverage.

Medicaid vs. Medicare

Medicaid is for low-income and disabled people, but Medicare is a public health program for anyone over the age of 65, regardless of their income. There are a few exceptions of other people who qualify for Medicare, including come people receiving Social Security disability and some patients with kidney failure. Unlike Medicaid, Medicare is administered at the federal level, and rules and coverage are the same across the country.

The eligibility rules for receiving Medicaid coverage can be extended to people who also qualify for Medicare. So, for instance a senior who is eligible for Medicare solely based on age, may also be eligible for Medicaid and can be covered under both programs. Medicaid covers more types of services and healthcare than Medicare does and can even pay for Medicare deductibles and up to 20 percent of medical charges a person faces that Medicare won’t cover.

What Does Medicaid Cover?

Exactly what services Medicaid covers for eligible enrollees depends on the state, but there are certain mandatory benefits. These are set by the federal government and must be covered by each state. A state can then choose to add additional benefits. The mandatory benefits include:

  • Inpatient and outpatient hospital care.
  • Nursing home care.
  • Home health care.
  • Physician care.
  • Early and periodic screening, diagnostic, and treatment.
  • Rural health clinic care.
  • Laboratory services.
  • X-ray imaging services.
  • Family planning.
  • Pediatric and family nurse practitioner care.
  • Freestanding birth center care.
  • Transportation for medical services.
  • Tobacco cessation programs for pregnant women.
  • Federal health center services.

Some of the benefits that states offer in addition to the mandatory coverage include prescription drugs, optometry, dental, and podiatry care, physical and occupational therapy, speech and language therapy, prosthetics, chiropractic care, hospice care, case management, and many others.

Access to and Quality of Care with Medicaid Coverage

About 70 percent of physicians accept Medicaid patients, as compared to 85 percent who accept patients with private insurance. Access to care for Medicaid patients is generally good, and patients rate their satisfaction with care and with access as high as those with private health insurance do. There are some gaps in access to care, though. These include some types of medical specialists, dentists, and psychiatrists. Patients covered by Medicaid fare much better and have much greater outcomes than those that are uninsured.

Millions of people depend on Medicaid coverage and expect to get quality care. Responsible for overseeing quality in the program is the Center for Medicaid and CHIP Services. Using certain guidelines, it is supposed to improve the quality of care, improve public health, and lower the costs of care. State governments and the federal government work together to maintain and improve the quality of care for patients enrolled in CHIP and Medicaid.

If you think you may be eligible for Medicaid, you can find out online through a few simple steps. You can also contact your local or county health department for more information and assistance with getting enrolled.