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You are here: Home / Anderson On Health Insurance / Different eligibility levels in a family for Medicaid

Different eligibility levels in a family for Medicaid

by David Anderson|  August 31, 20232:22 pm| 7 Comments

This post is in: Anderson On Health Insurance

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Medicaid is a collection of programs that serve different groups.  Each group has different eligibility criteria.  Some groups have asset limitations.  Other groups allow for substantially higher income limits than others. Some groups get a full benefit package while other people are served by Medicaid acting as a supplemental insurance policy to pay cost-sharing for Medicare.  It is messy.

Let’s take an example from North Carolina for a hypothetical family of four. We will make this easy and assume decent to good health for everyone.  Mom and Dad are both 40.  Kid 1 just turned 6 and Kid 2 is 11 months old.

Dad loses coverage if family income goes over 41% Federal Poverty Level and/or assets are over $3000.

Mom loses full coverage if family income goes over 41% FPL and/or assets are over $3000 AND she loses limited post-partum coverage if family income goes over 196% FPL.

Kid 1 loses full coverage if family income goes over 133% FPL.

Kid 2 loses full coverage if family income goes over 210% FPL.

Kids 1 and 2 are eligible for CHIP (NC Health Choice) which has similar but sparser coverage benefits than Medicaid up to 211% FPL.

Why does this matter?

It is quite plausible that if one person in a household is determined to be no longer eligible for Medicaid, most, if not all, of the other members in the household can retain their eligibility.  In states with Medicaid Expansion, an initial redetermination for a “legacy” Medicaid eligibility category may find that an adult is no longer eligible for that category but Medicaid Expansion is a second chance to maintain coverage with looser income and asset rules for a full benefit package.

Big big news on unwinding: CMS is making states who were conducting household-level determinations (rather than individual-level determinations) pause procedural terminations *and* reinstate coverage for affected people https://t.co/012OGOjvOy pic.twitter.com/HTf3lo1aMX

— Adrianna McIntyre (@adrianna.bsky.social) (@onceuponA) August 30, 2023

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    7Comments

    1. 1.

      sab

      August 31, 2023 at 2:54 pm

      Thank you. This stuff is so arcane that nobody much follows it who doesn’t need to,  yet it has really serious impact on real life people.

      Reply
    2. 2.

      Lobo

      August 31, 2023 at 3:07 pm

      A case where the following tweaks would work:

      • If one member eligible, the household eligible.  Or if member eligible for one benefit program than eligible for medicaid.
      • Medicaid overseen and run by feds
      • Medicaid insurer of last resort.

      I can dream.  But the admin friction here is great.  Streamlining benefit eligibility would increase coverage by a lot.

      Reply
    3. 3.

      Ohio Mom

      August 31, 2023 at 3:10 pm

      It occurs to me that as a whole, Medicaid — one version of which Ohio Son is enrolled in and which is the best health coverage any of us in our family has ever had — is as convoluted and inefficient as all other health care coverage in this great nation of ours.

      My experience with Ohio Son has been wonderfully simple, he can go to any doctor and we have yet to hit any roadblocks — no prior authorizations, etc. (I hope I did not jinx anything with that statement). I never worry about him being kicked off because he qualifies as a disabled person (and by having less than $2,000 in unsheltered assets).

      But I am reminded by this post that my experience is hardly universal. I also forget about the hoops we had to jump through to get to this point.

      (Growling noise)

      Reply
    4. 4.

      Yutsano

      August 31, 2023 at 4:03 pm

      @Ohio Mom: I think it was you who suggested that instead of expanding Medicare (which is not universal) we should focus on Medicaid (which is essentially single payer) which I thought about. It really would be the true universal coverage except it would make doctors take the biggest bath when it comes to payouts. I like the idea if we increase doctor payouts but lower hospital ones.

      Reply
    5. 5.

      Brachiator

      August 31, 2023 at 4:40 pm

      This whole thing is a mess and seems to reflect the idea that conservatives oppose universal health care, but reluctantly agree to provide some coverage for infants and children. But it is absurd that families should lose health care coverage for any of their children. Also, if parents lose or cannot get coverage,  the entire family might suffer.

      I understand that making this system work is a matter of political expediency, but we have to try to get beyond this.

      Reply
    6. 6.

      Ohio Mom

      August 31, 2023 at 4:47 pm

      @Yutsano: Yes, definitely pay doctors serving Medicaid patients more. Maybe work in some loan forgiveness in for the doctors who see Medicaid patients and are on the low end of the totem pole — family practice doctors, pediatricians and internists.

      One of the big reasons Medicaid has worked so well for Ohio Son is that Cincinnati children’s hospital and our university hospital system are both backstopped by the county’s Indigent Care levy. That money makes up the difference between what Medicaid will pay and what it really costs to provide medical care.

      Now of we lived somewhere else, someplace without a similar levy or source of extra funding, it would be another story. Doctors there would have a quota of how many Medicaid patients they can afford to have on their rolls.

      Reply
    7. 7.

      Ruckus

      August 31, 2023 at 5:38 pm

      I am going to go way out on a limb here.

      I actually use the VA and find that while it, like everything else in the world, has peculiarities, if you understand HOW it operates, it provides pretty good care. It is the most government run program one can find and while it isn’t perfect – humans – it is, if you understand how it does work and how it doesn’t work, far more than acceptable. One does have to accept that you are a tiny part of the whole but then what in humanity doesn’t require that?

      Reply

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