About Medicaid Rules
- Medicaid was created through Title XIX of the Social Security Act in 1965. It operates as a partnership between state and federal governments, both in funding and administration, though state participation is optional. Each state runs its own Medicaid program, and some states have created their own name for the program. All are overseen by the federal Centers for Medicare and Medicaid Services, or CMS, which ensures that federal regulations for services and eligibility are met.
- Eligibility for Medicaid varies from state to state. Medicaid may not cover all poor persons, though low income is a requirement for beneficiaries. To receive federal funding, state Medicaid programs are required to cover groups including low-income children, pregnant women, parents of eligible children and the disabled or elderly. States may also choose to cover approved optional groups to receive matching federal funding. Finally, states may choose to extend Medicaid coverage to those individuals who fit other categories, but are at an income level above their state's threshold. In some cases, people may qualify for aid from both Medicaid and Medicare.
- The law allows state Medicaid plans to be flexible in the medical services covered. As with the eligibility requirements, dtates are required to cover basic needs, such as vaccines for children, lab tests and nursing or home care, for example, in order to receive matching federal funds. Other approved but optional services that states can receive matching funds for include diagnostic and clinical services, prescription drugs and eye health needs. The benefits and approved medical services also vary from state to state.
- Medicaid works similarly to other health insurance plans. Medicaid submits payments to health care providers. Depending on individual state laws, participants may be responsible for a co-payment, or a portion of the cost, at the time of their medical service. Deductibles may also be imposed, but co-payments associated with emergency or family planning services are waved. In addition, pregnant women, children under the age of 18, and those who spend most of their income on hospital or nursing home care are not responsible for co-pays.
- Medicaid has certain restrictions. Legal resident aliens or other eligible aliens who entered the United States after August 22, 1996 are ineligible for Medicaid for five years after their arrival. If, at any time, a person no longer meets the requirements of any approved Medicaid group, their coverage will end. States also may place limitations on the length of hospital care, or number of doctor visits they will pay for. Medicaid also tends towards HMO-type coverage, which requires an approved primary care physician, who will refer patients to other approved specialists when necessary.
History
Eligibility
Benefits
Payments
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