What is Medicaid?

The Medicaid Program provides medical benefits to groups of low-income people, some who may have no medical insurance or inadequate medical insurance. Although the Federal Government establishes general guidelines for the program, the Medicaid program requirements are actually established by the state. Whether or not a person is eligible for Medicaid will depend upon the State where he or she lives.

Key Eligibility Groups

States are required to include certain types of individuals or eligibility groups under their Medicaid plans and they may include others. States’ eligibility groups will be considered on of the following: categorically needy, medically needy, or special groups.

Categorically Needy:

  • Families who meet states’ aid to families with dependent children (AFDC) eligibility requirements in effect on July 16. 1996
  • Pregnant women and children under age 6 whose family income is at or below 133% of the Federal poverty level.
  • Children ages 6 – 19 with family income up to 100% of the Federal poverty level.
  • Supplemental Security Income (SSI) recipients or in certain states aged, blind, and disabled people who met requirements that are more restrictive than those of the SSI program.
  • Individuals and couples who are living in medical institutions and who have monthly income up to 300% of the SSI income standard (Federal Benefit Rate)

Medically Needy:

The medically needy have too much money and in some cases resources like savings to be eligible as categorically needy. If a state has a medically needy program, it must include pregnant women through a 60 day postpartum period, children under 18, certain newborns for one year, and certain protected blind persons.

States may also, at the State’s option, provide Medicaid to”

  • Children under age 21, 20, or 19 who are full-time students. If a state does not want to cover all of these children, it can limit eligibility to reasonable groups of these children.
  • Caretaker relatives (relatives or legal guardians who live with and take care of children)
  • Aged persons 65 and older
  • Blind persons
  • Disabled persons
  • Persons who would be eligible if not enrolled in a health maintenance organization

Special Groups:

  • Medicare Beneficiaries – Medicaid pays Medicare premiums, deductibles, and coinsurance for Qualified Medicare Beneficiaries – individuals whose income is at or below 100% of the Federal Poverty Level and whose resources are at or below twice the standard allowed under SSI. There are additional groups for whom Medicare related expenses are paid by Medicaid – Medicare beneficiaries with income greater than 100% but less than 135% of the Federal poverty level.
  • Qualified working disabled individuals – Medicaid can pay Medicare Part A premiums for certain disabled individuals who lose Medicare coverage because of work. These individuals have income below 200% o f the Federal poverty level.
  • States may also improve access to employment, training, and placement of people with disabilities who want to work through expanded Medicaid eligibility. Eligibility can be extended to working disabled people between ages 16 and 65 who have income and resources greater than that allowed under the SSI program.
  • There are two eligibility groups related to specific medical conditions that states may include under their Medicaid plans. One is a time-limited eligibility group for women who have breast or cervical cancer and the other is for people with tuberculosis who are uninsured.