Medicaid Made Clear: What Medicaid is, who Medicaid serves & the history of Medicaid
Introduction to Medicaid
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The Value of Medicaid Managed Care
The History of Medicaid
Medicaid began as part of the Social Security Act of 1965. The original law gave states the option of receiving federal funding to help provide health care coverage to children whose families have a low income, their caregiver relatives, people who are blind and people who are disabled. Throughout time, the federal government has strengthened and expanded the rules and requirements for states administering Medicaid. Through Medicaid expansion some states now extend coverage to other low-income adults.
Medicaid is established and provides states with the option of receiving federal funding for providing health care services to certain groups.
Early, Periodic Screening, Diagnosis, and Treatement (EPSDT) comprehensive health services benefit is established for all children receiving Medicaid.
Medicaid eligibility for the elderly and people with disabilities was linked to the eligibility for the newly enacted Federal Supplement Security Income (SSI) program.
Home- and Community- Based Services (HCBS) waivers were established.
Medicaid coverage for pregnant women and infants (up to 1 year of age) up to 100% of the Federal Poverty Level (FPL) was established as a state option.
Medicaid coverage of pregnant women and children (under age 6) up to 133% of the Federal Poverty Level was mandated; expanded EPSDT requirements were established.
Federal Medicaid rules required coverage for children ages 6-8 in families under 100% of the FPL. The rules also created the prescription drug rebate program.
Temporay Assistance to Needy Families (TANF) replaced a program that linked Medicaid enrollment/termination with the receipt of Welfare cash assistance.
The Balance Budget Act of 1997 created the State Children's Health Insurance Program (SCHIP).
The Ticket to Work Incentives Improvements Act allowed states to cover working people with disabilities up to 250% FPL and charge income-based premiums.
The Supreme Court ruled on a case that established expanded civil rights for people with disabilities. They determined that people with disabilities have a qualified right to receive state funded supports and services in the community rather than in nursing homes or other formal settings.
The Affordable Care Act was signed, providing states with the option to expand Medicaid to adults who earn up to 138% of the FPL.
As of February, 2019, 72,232,316 individuals are currently enrolled in Medicaid and CHIP.
Defining Medicaid Language
Did you know?
When it comes to Medicaid, there is a lot of misinformation and misunderstanding out there. Medicaid provides health insurance coverage to people who may be experiencing low incomes, people with disabilities, and people who are older. Here are some facts about Medicaid.
What is the difference between Medicaid and Medicare?
Examples of Medicaid Eligibility
- Pregnant Woman
- Medicaid Expansion
- Activities of Daily Living (ADLs)
- Dually Eligible
Medicaid – Children of low-income families
JJ is 10 years old and lives in Louisiana with his father and 8-year-old brother. This means there are three people in his household. His mother recently died after battling cancer. His dad is employed as a maintenance worker for a local property management company.
JJ’s dad earns $26,635/year.
JJ and his brother are covered under Medicaid because his dad earns less than $30,288/year.
Tanya is a recently single mother with one child who lives in Texas. She is pregnant and works full-time as a restaurant hostess making the federal minimum wage of $7.25 per hour. She works full-time and earns just over $15,000 a year. Because she has a child, her household size is 2 people.
Her child qualifies for Medicaid because she earns less than 138% of the Federal Poverty Level or $25,365 per year for a 2 person household.
At this time Tanya also receives Temporary Assistance for Needy Families (TANF). TANF is a time-limited benefit program that helps parents or caregivers. Each state determines what benefits are available for those who qualify. In Texas, Tanya can receive a cash benefit to help with things like housing and childcare.
Since Tanya needs to earn less than $33,820 per year to qualify for Medicaid as a pregnant woman, she is also currently covered. However, once her child is born she will not qualify for Medicaid as a caregiver parent in Texas since she makes more than $3,626 per year, or 17% of the Federal Poverty Level with a household size of 3, and will no longer have health care coverage. Each state sets the Medicaid eligibility level for parents and caregivers of children and that level is approved by the federal government.
If Tanya’s state expanded Medicaid, she would qualify for Medicaid after giving birth since she makes less than $29,435 per year with a 3 person household.
After working as an administrative assistant at the same company for more than 25 years, Lisa was part of a large lay off due to downsizing. She is currently working at a local grocery store while she is looking for another office position.
She earns the federal minimum wage of $7.25 per hour. She works an average of 35 hours a week, earning just over $1,000 a month.
Lisa qualifies for Medicaid after her state expanded Medicaid eligibility to low-income working adults and she makes less than $17,236 per year.
Example of person needing help with ADLs
Susan is an 80-year-old woman who was living on her own until she fell and broke a hip. Her doctor determined that she should move to a nursing home to recover from surgery. Susan was already on Medicaid due to her low income and small amount of assets and on Medicare because she is over 65 years old.
After recovering from her hip fracture, she was assessed to determine if she needed help with activities of daily living (ADLs). The assessment showed that she needed help dressing, walking from one place to another, using the bathroom and showering. She also needed help remembering to take her medications and eat three meals a day.
Based on the ADL assessment, Susan’s doctors and family agreed that she could no longer live at home and would need to be moved into a nursing facility for her safety.
Rebecca is a 35-year-old woman who survived a serious car accident as a child, leaving her with physical and cognitive disabilities. Despite her disabilities, including the requirement to use a wheelchair, Rebecca lives independently with the help of Supplemental Security Income (SSI).
Rebecca has a part-time job at a local manufacturing facility. She earns $13 per hour, equaling roughly $15,600 a year.
Rebecca is a Dual Eligible because she qualifies for coverage under both Medicare and Medicaid. She qualifies for Medicare because she’s permanently disabled and receives disability benefits. She qualifies for Medicaid because she earns less than $4,249 per month.
Medicaid Coverage & Benefits
The federal government requires that states provide certain mandatory medical benefits to people who are eligible for Medicaid. States can choose to provide additional, optional benefits.
- Hospital visits and stay
- Doctors’ office visits
- Prenatal care and delivery
- Nursing home services
- Home health services
- Early childhood screening which includes, vision and hearing testing, as well as a comprehensive physical exam, developmental history, appropriate immunizations, laboratory tests, dental care, and health education.
- Emergency medical transportation
Children's Health Insurance Program (CHIP)
Early, Periodic, Screening, Diagnosis and Treatment (EPSDT)
Activities of Daily Living (ADLs) and Instrumental Activies of Daily Living (IADLs)
ADLs and IADLs are terms used for the different levels of support an individual needs to remain in their home and active in the community.