Frequently Asked Questions About Medicaid

Medicaid is a government health care assistance program that provides comprehensive coverage to many Americans, such as low-income adults, senior citizens, pregnant women, children and people with disabilities. Review some of the most common questions and concerns regarding Medicaid below.

Where does Medicaid get its funding from?

Medicaid is funded jointly by states and the federal government. The health care program is administered by each individual state and while they must adhere to federal parameters, it is at the state’s discretion to determine the type, duration, amount and scope of services beneficiaries can be awarded.

What are some of the benefits of Medicaid?

Medicaid provides health care coverage to millions of Americans. Since each individual state administers Medicaid, it is at the state’s discretion to determine what “optional” benefits it wants to include in the Medicaid program. While states have the liberty of choosing “optional” benefits like prescription drugs, case management, occupational therapy and physical therapy, “mandatory” benefits must be provided.

What are some of the “mandatory” benefits of Medicaid?

“Mandatory” benefits are automatically included in every state’s Medicaid program. Some of the “mandatory” benefits of Medicaid include inpatient and outpatient hospital services, physician services, laboratory and x-ray services, home health services, family planning services, EPSDT (early and periodic screening, diagnostic, and treatment services), nurse midwife services, transportation to medical care, rural health care clinic services and more. To learn all of the “mandatory” and “optional” benefits that Medicaid can provide, download our free guide.

What is Obamacare?

The Affordable Care Act (ACA), commonly referred to as “Obamacare”, makes Medicaid available to more people. The law innovated Medicaid by making it easier for applicants to apply and enroll in the appropriate coverage program. Obamacare created one set of income counting rules and a single application process. Obamacare provides individuals with subsidies, which lower costs for household with income between 100 and 400 percent of the federal poverty level.

What if I have a pre-existing condition?

Under the Affordable Care Act, insurance companies cannot refuse individuals coverage because of a “pre-existing” condition. This disables insurance companies from trying to charge individuals with health conditions like diabetes, asthma or cancer more money or denying them for coverage. This law restricts insurance companies from limiting benefits to individuals with a pre-existing condition.

How do I know if I am eligible for benefits?

Since Medicaid is administered by each individual state, eligibility requirements will vary. To participate in the government health care program, applicants must belong to a distinct group, such as SSI recipients, low-income families, children and qualified pregnant women. States have full discretion when determining what additional plans for coverage they may provide for other groups that not listed. The best way to know who qualifies for benefits is to contact your state’s Medicaid agency.

When will I receive my Medicaid benefits?

Once an applicant is accepted into the Medicaid program, he or she will be able to receive benefits from the day of application approval or the first day of the month, if the applicant was considered eligible during that period he or she had applied. Applicants can also be covered retroactively for up to three months prior of their application submittal, if they were considered eligible during that period.

When will my Medicaid benefits end?

A Medicaid participant’s benefits will end when they are determined no longer eligible to meet the requirements to be part of the program. Coverage usually stops at the end of the month after a participant is determined ineligible.

Does Medicaid cover pregnancies, nursing homes, mental health or long-term care?

States are required to provide “mandatory benefits”, while others are “optional”, so they may vary. To find out what benefits are covered by your state, contact your state Medicaid agency. Learn more about the optional benefits available at the state’s discretion in our detailed guided here.

What will happen to individuals that are told they are not eligible for government health care assistance?

Individuals still will have the option to purchase health plans through the health insurance marketplace if they do not meet the eligibility requirements for Medicaid or any other government health care assistance. The marketplace will provide a timely notice to an applicant of any eligibility determination made. 

If I was denied for coverage how can I make an appeal?

Individuals denied Medicaid benefits will find out through a written notice in the mail. Typically, Medicaid provides a determination status within 90 days if applicants have a disability, or 45 days for individuals who applied for any other reason than a disability. The notice will include in detail reasons why an individual was denied and if an appeal is possible. Applicants that were denied can choose to request a hearing for certain denials to prove they are eligible for coverage. The denial will include the deadline an applicant has to request an appeal. Once an applicant’s appeal is received and processed, he or she will be notified with a hearing date. If an applicant does not appear for their hearing or call into the hearing via phone, the appeal will be dismissed.