Medicaid Explained

If you have a family member with special needs, you know how necessary it is to have health insurance to pay for medical care. Yet when the responsibility of caring for someone with a disability prevents you from working full time, you may be ineligible for health insurance through your job.

Enter Medicaid, a program that provides health coverage and health services to nearly 60 million low-income Americans. Created by Congress in 1965 under Title XIX of the Social Security Act, it is jointly funded by the federal government and state governments. While the federal government provides general guidelines for Medicaid, it’s up to each state to administer its own program. This means that each state decides who is eligible, what type of services will be provided and how much will be paid to providers for the services.

“If you’ve seen one state’s program, you’ve seen one state’s program,” says Grace-Marie Turner, a member of the Federal Medicaid Commission, a group of 15 people appointed by Secretary of the Department of Health and Human Services Mike Leavitt, to make recommendations for Medicaid reform. “Every state has different rules.”

Determining Eligibility

One thing that is true for all states is that Medicaid is a health care financing program only for the most needy people. This means that those receiving services must not only have low income but limited resources. “The income and asset guidelines for Medicaid vary from state to state but are generally similar to those for Supplemental Security Income (SSI),” says Tracy Miller, special needs coordinator for Protected Tomorrows, Inc.

In other words, certain income criteria must be met, and assets must be less than $2,000. This includes money in checking, savings and retirement accounts, stocks, bonds, mutual funds and other investments including real estate (other than the home in which the qualifying person is living).

Although individual states have discretion in deciding which groups are eligible for Medicaid services, in order to receive federal funds, they are required to provide Medicaid coverage for certain groups (called “categorically needy”). These include:

  • Families who meet eligibility requirements for their states’ Aid to Families with Dependent Children program
  • Pregnant women and children younger than age 6 with family income at or below 133 percent of the federal poverty level (FPL)
  • Children age 6 to 19 whose families have income up to 100 percent of the FPL
  • Caretakers of children younger than age 18 (or 19 if still in high school). Caretakers are defined as relatives or legal guardians who live with and take care of children
  • Recipients of SSI, although in certain states, the aged, blind and individuals with disabilities must meet more restrictive state requirements
  • Those who are living in medical institutions and have monthly income up to 300 percent of the SSI standard


In addition, states may offer medical coverage to the “medically needy,” those who have too much income and/or assets to qualify as categorically needy and special groups such as women with breast or cervical cancer or people with tuberculosis.

Services Provided by Medicaid

What services are covered under Medicaid? Again, there are variations between states, but those who are categorically needy are eligible for:

  • Inpatient hospital coverage (excluding mental health institutional care)
  • Outpatient hospital services
  • Pediatric and family nurse practitioner services
  • Physician services
  • Lab and X-ray services
  • Medical and surgical dental services
  • Home health services/supplies for those eligible for skilled nursing services
  • Early and periodic screening, diagnostic and treatment services for individuals younger than 21 years of age
  • Nursing facility services for those aged 21 and older
  • Prenatal care, nurse-midwife services, family planning services and supplies


In addition, states have an option to provide other services such as:

  • Clinic services
  • Certain facilities that care for individuals with mental retardation
  • Eye exams and glasses
  • Preventive dental care
  • Prescribed medications
  • Nursing facility services for the aged and individuals with disabilities
  • Prosthetic devices
  • Care for patients with tuberculosis


“Medicaid can also pay for community-based habilitative services for individuals with special needs,” Miller says. “Many states offer Waiver programs in which the services normally provided in an institutional setting are instead provided in the community. The individual must remain Medicaid eligible in order to receive these services, but they range from group home residential programs to respite, recreation and vocational services to the individual living in their own home.”

While Medicaid, with minimal or no co-pays, deductibles or premiums, sounds like the ideal health plan, there are shortcomings to such a large government-funded program. “Whenever legislators need to cut the budget, they take money from Medicaid first,” Miller says.

This may mean that previously covered services, especially those services that are optional, may no longer be provided. For example, your state might provide dental cleanings and exams for adult Medicaid recipients and then due to monetary cutbacks offer only emergency or surgical treatment. This would leave the recipient with no option but to pay for preventive care or go without.

Budget constraints affect administration of the Medicaid program, too, Miller says. The volume of Medicaid recipients along with staff reductions due to budget cuts can mean a long wait for help with an application or a problem.

Added to this are reimbursement issues. Medicaid pays service providers directly, but payment – which is established according to a set standard that assigns a value to a particular service – is notoriously poor. And providers – who have agreed to accept Medicaid reimbursement as full payment for service – are not able to charge patients for the difference between their customary charge and the Medicaid reimbursement. This means that fewer doctors participate in the Medicaid program. “Medicaid pays doctors and hospitals so little that people have trouble finding a doctor,” Turner says.

Despite the problems, Medicaid is an important program. If funding were cut, millions of people would be without basic medical care. If you want to find out if you’re eligible for Medicaid, you can learn more here. A Protected Tomorrows Advocate can also help you with the application process.