This is general information, not insurance, medical, legal or financial advice. Medicaid is specific to the United States, and its rules vary by state and change over time. Your state Medicaid office is the authority on eligibility and benefits.
What Medicaid is for
Medicaid is a public health coverage program for people with limited income and resources. It is funded jointly by the federal government and the states, and run by the states within federal guidelines. The program’s purpose is to help people who would otherwise have difficulty paying for medical care get coverage.
It is different from Medicare, which is a separate federal program built mainly around age and disability. The two are sometimes confused, and some people have both. The structure of Medicare is covered in the discussion of Medicare parts.
Why rules differ by state
Because states administer the program, many important choices are made at the state level. As a result, you may see differences in:
- Eligibility groups and income limits. States decide, within limits, which groups to cover and how high income can be.
- Covered services. Some services are required by federal rules, while others are optional, so the list varies.
- Delivery. Many states use private managed care companies to run Medicaid coverage, which means members often choose among plans with their own provider networks. Others pay providers directly on a fee-for-service basis, or use a mix.
- Program names. States often brand their program with a different name, so you might not see the word Medicaid on your card.
- Expansion choices. Whether and how a state extends coverage to more adults has differed across states and has been shaped by laws and court decisions. Check the current position in your state.
The practical result is that the answer to “do I qualify?” can be different for two people with the same income who live in different states.
Who commonly qualifies
Groups commonly covered, depending on state rules, include:
- Children and, in many cases, teens from lower-income households. A related program for children is covered in the overview of child coverage programs.
- Pregnant women.
- Parents and caretaker relatives with low income.
- Adults with low income, in states that cover them broadly.
- Older adults with limited income and resources.
- People with disabilities.
Eligibility often involves several tests, such as household income, household size, citizenship or immigration status, state residency, and, for some groups, assets. Different groups can have different tests, and how income is counted is not the same as what shows on a tax return.
What Medicaid typically covers
Coverage varies by state and by eligibility group, but commonly includes:
- Doctor and clinic visits.
- Hospital stays and emergency room care.
- Preventive care and screenings.
- Prescription drugs, usually with a formulary.
- Maternity and newborn care.
- Mental health and substance use treatment.
- Long-term services, such as nursing facility care and, in many states, in-home care. Long-term care is a major part of the program’s spending for older adults and people with disabilities.
Some benefits, such as adult dental, vision or hearing aid coverage, are often optional for states and so differ more. If a specific service matters to you, ask the state office whether it is covered.
Costs to the member
Medicaid is generally designed to keep costs low. Many members pay nothing or very little. Where there are charges, they are usually small copayments, and federal rules limit what states can charge certain groups. A few states have charged modest premiums for some groups. Because it varies, the member handbook for your plan is the best source.
Medicaid providers generally agree to accept the program’s payment as payment in full, so protections around balance billing tend to be stronger than in private coverage, though exceptions may exist. Not every provider takes Medicaid, so it is worth checking whether your doctor participates before you rely on it.
Applying and staying covered
- Enrollment is typically open year-round for people who qualify, unlike the annual window for many private plans. Applications can usually be made online, by phone, by mail or in person through the state agency, and through the marketplace in many states.
- Documentation. You may be asked for proof of income, identity, residency and immigration status.
- Decisions. The agency sends a written notice. If you are denied, the notice should explain the reason and your right to appeal, which resembles the process for a denial letter in private insurance.
- Renewals. Coverage typically needs to be renewed on a regular schedule. People sometimes lose coverage because they never saw or answered a renewal notice, so keeping your contact information current matters.
If you lose Medicaid, check whether you qualify for another program or a special enrollment period for marketplace coverage. Losing coverage can open that window, but time limits may be short.
Where Medicaid fits
For some people, Medicaid is their only coverage. For others it complements other coverage: it may help an older adult with costs that Medicare does not cover, or cover a child who has a parent with employer insurance. How the pieces coordinate, and which pays first, is set by program rules.
Medicaid is a large and complicated program. Treat any general description as a starting point, and confirm specifics with your state agency or a local navigator.