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| Medicaid FAQs |
| the Health Care Financing Administration |
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What is the difference
between Medicare and Medicaid?
Who is eligible
for Medicaid?
Where do I apply
for Medicaid?
Who do I contact with
questions about Medicaid eligibility and benefits
?
When does
coverage
start and stop?
How are
payments
determined?
Are there any
deductibles, coinsurance, or co-payments
?
Who do I contact with
questions about services
covered by Medicaid?
Q:
What is the difference between Medicare and Medicaid?
A:
Medicare is an insurance program. Medical bills are paid from trust funds that those who are covered have paid into. It primarily serves people over 65 and younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Health Care Financing Administration, an agency of the federal government.
Medicaid is an assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal/state program, so it varies from state to state. It is run by state and local governments according to federal guidelines
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Q:
Who is eligible for Medicaid?
A:
States have some discretion in determining which groups their Medicaid programs will cover and the financial criteria for Medicaid eligibility. To be eligible for federal funds, states are required to provide Medicaid coverage for most individuals who receive federally-assisted income maintenance payments, as well as for related groups not receiving cash payments.
Medicaid doesn't provide medical assistance for all poor persons. Even under the broadest provisions of the federal statute (except for emergency services for certain persons), the Medicaid program doesn't provide health care services, even for very poor persons, unless they are in a designated group. Low income is only one test for Medicaid eligibility. Assets and resources are also tested against established thresholds. Categorically needy persons who are eligible for Medicaid may or may not also receive cash assistance from the TANF program or from the SSI program. Medically needy persons who would be categorically eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses. Eligibility requirements for Medicaid benefits vary for each state. Contact your state Medicaid officials for more information.
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Q:
Where do I apply for Medicaid?
A:
A: Individuals qualified for Medicaid can apply at local state welfare offices, state public health departments and state social service agencies.
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Q:
Who do I contact with questions about Medicaid eligibility and benefits?
A:
Eligibility intake processes and benefits are determined and administered by the state. If you don't have access to a state contact, the American Public Human Services Association site has a list of State Medicaid Directors' offices at http://medicaid.aphsa.org/members.htm.
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Q:
When does coverage stop and start?
A:
Coverage may start retroactive to any or all of the three months prior to application, if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person's circumstances change. Most states have additional "state-only" programs to provide medical assistance for specified poor persons who don't qualify for the Medicaid program. No federal funds are provided for state-only programs.
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Q:
How are payments determined?
A:
Medicaid operates as a vendor payment program, with payments made directly to the providers. Providers participating in Medicaid must accept the Medicaid reimbursement level as payment in full. Each state has relatively broad discretion in determining (within federally-imposed upper limits and specific restrictions) the reimbursement methodology and resulting rate for services, with three exceptions:
- For institutional services, payment may not exceed amounts that would be paid under Medicare payment rates
- For disproportionate share hospitals ("DSHs"), different limits apply
- For hospice care
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Q:
Are there any deductibles, coinsurance, or co-payments?
A:
States may impose nominal deductibles, coinsurance, or co-payments on some Medicaid recipients for certain services. Emergency services and family planning services must be exempt from such copayments. Certain Medicaid recipients must be excluded from this cost sharing, including:
- Pregnant women
- Children under age 18
- Hospital or nursing home patients who are expected to contribute most of their income to institutional care
- Certain defined HMO enrollees
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Q:
Who do I contact with questions about services covered by Medicaid?
A:
Within broad federal guidelines, states determine the amount and duration of services offered under their Medicaid programs. The amount, duration, and scope of each service must be sufficient to reasonably achieve its purpose. States may place appropriate limits on a Medicaid service, based on such criteria as medical necessity or "utilization control." For example, States may place a reasonable limit on the number of covered physician visits or may require prior authorization to be obtained prior to service delivery.
Health care services identified under the EPSDT program as being "medically necessary" for eligible children must be provided by Medicaid, even if those services aren't included as part of the covered services in that state's plan.
With certain exceptions, a state's Medicaid plan must allow recipients freedom of choice among health care providers participating in Medicaid. States may provide and pay for Medicaid services through various prepayment arrangements, such as a health maintenance organization ("HMO"). In general, states are required to provide comparable services to all categorically needy eligible persons.
There is an important exception related to home and community-based services "waivers," under which states offer an alternative health care package for persons who would otherwise be institutionalized under Medicaid. States aren't limited in the scope of services they can provide under such waivers, so long as they are cost effective (except that, other than as a part of respite care, they may not provide room and board for such recipients).
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Information courtesy of the Health Care Financing Administration.
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