Medicaid is going to be a big area of debate, so let’s go over the mechanics of Medicaid in any state. I will be speaking at a very high level and without too much state specific detail. This is not a state specific guide-book to Medicaid. It is just a reference guide to build a light framework.
What is Medicaid
Medicaid is a federal-state partnership program that originated in 1965 to pay for health care and long term care for people who can not afford it. Eligibility has expanded significantly over time. The program varies significantly by state.
Who gets covered
There are several major groups that are eligible to receive coverage. Each state has to meet minimum baselines and can elect to change eligibility criteria to expand coverage to certain groups. But let’s break it down now:
- Old people in nursing homes
- Sick to very sick people
- Poor kids
- Poor pregnant women
- Working poor adults (Medicaid Expansion in the ACA)
These are massive overgeneralizations and are a bit flippant. Eligibility varies by state. Some states like Massachusetts would cover childless adults up to or over the federal poverty line even before the ACA passed. Other states like Florida won’t cover non-chronically ill childless adults at any income level.
Who pays for Medicaid
We all do. Medicaid is a federal-state partnership. For non-expansion groups, the Feds pay between one and three dollars for every dollar a state spends. For Expansion the feds under current law as of Monday morning pay nineteen dollars for every dollar the state spends, this will decrease to nine federal dollars for every state dollar. It is usually paid for out of general revenue instead of a dedicated tax like Medicare or Social Security.
What are the benefits
Medicaid is comprehensive health insurance. It covers the typical hospital, doctor, prescription, rehab charges. It also will cover some dental and vision services. Additionally, Medicaid tends to be one of the biggest payers for mental and behavioral health services in the country. Since Medicaid also acts as a long term care supplement, it will spend a lot of money on nursing homes and long term home care.
How is care paid for
There are two primary methods of paying for care. In some states, there is a fee for service component where the state (or a contractor for the state) processes claims and acts as a pass through entity for federal money. This is becoming less common. The more common method is some type of Medicaid Managed Care Organization (MCO) which is an HMO for Medicaid. Here the state gives the MCO a fixed sum of money every month to cover the expenses of its members. Each state will do things differently. Some states are 100% MCO with a sole source MCO covering all benefits. Other states will split physical health, behavioral health and long term care into separate MCO contracts. Other states will have a hybrid fee for service and MCO model. It varies. [DISCLAIMER— I used to work as a data analyst for a Medicaid Managed Care Organization, UPMC Health Plan — I don’t think the MCO model is intrinsically evil ]
Do I know someone on Medicaid?
I would be shocked if you did not.
Who should I talk to about nursing home assistance
Give the wonderful people at your local Area Agency on Aging (AAA) a call. They know this stuff cold and they know your state laws way better than someone on the internet ever will.
If I’m not old, how do I apply
There are a lot of pathways. The first is to go on Healthcare.gov or your state exchange and apply. Currently there is a “no wrong door” process where the exchanges will forward your information onto the state Medicaid program if you look like you qualify. If you don’t want to deal with that, contact the local county assistance office. If you can’t find that, call the local hospital and ask to speak to a social worker. They might not be able to get you started but they will be able to tell you where to go to get started.