The BBA included a State option known as Programs of All-inclusive
Care for the Elderly (PACE). PACE provides an alternative
to institutional care for persons aged 55 or older who require
a nursing facility level of care. The PACE team offers and
manages all health, medical, and social services and mobilizes
other services as needed to provide preventative, rehabilitative,
curative, and supportive care. This care, provided in day
health centers, homes, hospitals, and nursing homes, helps
the person maintain independence, dignity, and quality of
life. PACE functions within the Medicare program as well.
Regardless of source of payment, PACE providers receive
payment only through the PACE agreement and must make available
all items and services covered under both Titles XVIII and
XIX, without amount, duration, or scope limitations and
without application of any deductibles, copayments, or other
cost sharing. The individuals enrolled in PACE receive benefits
solely through the PACE program.
Amount and Duration of Medicaid
Services
Within broad Federal guidelines and certain limitations,
States determine the amount and duration of services offered
under their Medicaid programs. States may limit, for example,
the number of days of hospital care or the number of physician
visits covered. Two restrictions apply: (1) limits must
result in a sufficient level of services to reasonably achieve
the purpose of the benefits; and (2) limits on benefits
may not discriminate among beneficiaries based on medical
diagnosis or condition.
In general, States are required to provide comparable amounts,
duration, and scope of services to all categorically needy
and categorically related eligible persons. There are two
important exceptions: (1) Medically necessary health care
services that are identified under the EPSDT program for
eligible children, and that are within the scope of mandatory
or optional services under Federal law, must be covered
even if those services are not included as part of the covered
services in that State's Plan; and (2) States may request
"waivers" to pay for otherwise uncovered home
and community-based services (HCBS) for Medicaid-eligible
persons who might otherwise be institutionalized. As long
as the services are cost effective, States have few limitations
on the services that may be covered under these waivers
(except that, other than as a part of respite care, States
may not provide room and board for the beneficiaries). With
certain exceptions, a State's Medicaid program must allow
beneficiaries to have some informed choices among participating
providers of health care and to receive quality care that
is appropriate and timely.
Who Is Eligible for Medicaid?
Many groups of people are covered by Medicaid. Even within
these groups, though, certain requirements must be met.
These may include your age, whether you are pregnant, disabled,
blind, or aged; your income and resources (like bank accounts,
real property, or other items that can be sold for cash);
and whether you are a U.S. citizen or a lawfully admitted
immigrant. The rules for counting your income and resources
vary from state to state and from group to group. There
are special rules for those who live in nursing homes and
for disabled children living at home.
Your child may be eligible for coverage if he or she is
a U.S. citizen or a lawfully admitted immigrant, even if
you are not (however, there is a 5-year limit that applies
to lawful permanent residents). Eligibility for children
is based on the child's status, not the parent's. Also,
if someone else's child lives with you, the child may be
eligible even if you are not because your income and resources
will not count for the child.
In general, you should apply for Medicaid if your income
is low and you match one of the descriptions below. (Even
if you are not sure whether you qualify, if you or someone
in your family needs health care, you should apply for Medicaid
and have a qualified caseworker in your state evaluate your
situation.)
Pregnant Women
Apply for Medicaid if you think you are pregnant. You may
be eligible if you are married or single. If you are on
Medicaid when your child is born, both you and your child
will be covered.
Children and Teenagers
Apply for Medicaid if you are the parent or guardian of
a child who is 18 years old or younger and your family's
income is low, or if your child is sick enough to need nursing
home care, but could stay home with good quality care at
home. If you are a teenager living on your own, the state
may allow you to apply for Medicaid on your own behalf or
any adult may apply for you. Many states also cover children
up to age 21.
Person who is Aged, Blind, and/or Disabled
Apply if you are aged (65 years old or older), blind, or
disabled and have low income and few resources. Apply if
you are terminally ill and want to receive hospice services.
Apply if you are aged, blind, or disabled; live in a nursing
home; and have low income and limited resources. Apply if
you are aged, blind, or disabled and need nursing home care,
but can stay at home with special community care services.
Apply if you are eligible for Medicare and have low income
and limited resources.
Some Other Situations
Apply if you are leaving welfare and need health coverage.
Apply if you are a family with children under 18 and have
very low income and few resources. (You do not need to be
receiving a welfare check.) Apply if you have very high
medical bills, which you cannot pay (and you are pregnant,
under 18 or over 65, blind, or disabled).
The following websites provide Screening Tools to help
you see if you may be eligible for a variety of governmental
programs: www.govbenefits.gov
and http://www.benefitscheckup.org/
Is everyone who is poor and in need of health insurance
able to receive Medicaid?
No. Medicaid eligibility in nearly every state is limited
to children; pregnant women; families with dependent children;
persons who are blind or disabled: and persons 65 or older.
A few states cover single healthy adults within certain
income guidelines. Other state requirements must also be
met. For more information, contact your local
Medicaid office or your state.
I lost my job, or I lost my health coverage at work,
and no longer have any insurance. How can I get health insurance
now?
You may qualify for Medicaid. Even if you do not qualify
for Medicaid, some states have other progams that may help
you. Your local Medicaid office or your state can provide
you with information. For more information on applying for Medicaid,
visit the How do I apply for Medicaid? FAQ.
COBRA insurance allows you to keep your health insurance
if you lose your job. Federal law requires employers to
offer this option. If you elected COBRA continuation coverage
when you were working, you can keep your health coverage
but you must pay the full premium. In some states, Medicaid
helps pay for the premium.
For more information about COBRA, contact the Department
of Labor (DOL) at 1-866-444-3272, or access DOL's website
at www.dol.gov
if you were employed by a private sector employer. If you
were employed by a state or local government employer, contact
Public Health
Services, or the CMS
website.
If your spouse has health coverage at work, you may be
able to enroll in your spouse's health plan under a "special
enrollment" procedure authorized under federal law.
You must request enrollment within 30 days of loss of your
coverage. Your state department of insurance can provide
you with information about this procedure.
How do I apply for Medicaid?
You apply for Medicaid in the state in which you live. You
can obtain and submit an application at your local Medicaid
office. The phone number for your local office can be found
in the blue pages of your phone book. Frequently, the office
listing is under "medical assistance". If you
have trouble finding the local office phone number in your
phone book, call your local Social Security office. They
can give you the phone number and address of your local
Medicaid office.
Some states also let you apply on the Internet, by telephone,
or at locations in the community, such as community health
centers.
Most states have a toll-free number to help answer your
questions. The toll-free operators can provide you information
on how and where to apply. You can find the state contact
information by visiting the CMS
website and selecting your state program from the map.
How much money can you make and still get Medicaid?
It varies depending on the eligibility group you fall into.
Each state sets an income limit for each Medicaid eligibility
group and determines what income counts towards that limit.
You will need to contact your local Medicaid office or your
state to find out what the income limits are and how much
of your income counts.
This resource was developed in 2004. Some of the content may be out of date or no longer relevant. PHA is working to update and re-organize this guide. We apologize for any inconvenience.
