So Medicare and Medicaid are two terms that a lot of people seem to mix up on occasion.
They are both important insurance programs, but they are run and managed through different levels of government. They also provide different types and degrees of coverage, and the process to get them is different, as is the process of losing that coverage.
To make it more confusing both programs are part of the larger federal program Center for Medicare and Medicaid Services. CMS is the single largest insurance provider in the US, and could be a model for universal health care.
What is Medicaid?
Medicaid is a state-level insurance program. Each state has its own form of Medicaid with its own rules. In many cases, there are multiple options for coverage.
In New Jersey, for example, there is no more original Medicaid, but each county has four or five HMOs to choose from.
When you first enroll in Medicaid, you generally can select which HMO(health maintenance organization) will cover you, though sometimes they will automatically enroll you in one and then allow you to choose during the next open enrollment period.
Open enrollment for Medicare and Affordable Care Act coverage is generally October into December, and the selected coverage starts in January. It appears that Medicaid’s open enrollment period may be during a different time period, depending on what state you live in.
Each state has its own Medicaid rules and services, but generally, Medicaid coverage has fewer options than Medicare but does have the advantage of paying the entirety of each bill. Medicare, on the other hand, generally covers 80% of each expense.
Often Medicaid HMO coverage varies even on the county level, so your county might not have a particular option, even if it is available in other counties in your state.
Your Medicaid program controls what doctors you are eligible to see, and what medications are covered, so it is very important to look over your options every year to make sure you continually have the best coverage.
The information can be confusing and poorly explained, but it still remains crucial.
There are some programs out there that can help you know your options, but they can make mistakes too, so you are better served making multiple calls and having a list of your desired doctors and needed medications.
Some Medicaid programs allow you to see doctors outside of their preferred network, usually at a higher charge(if a program covers all but one specialist you see once or twice a year it may be worth doing), but some insist that you can only see doctors within their network.
Medicaid also often has a companion program, Children’s Health Insurance Program(CHIP), for low-income children 18 and under.
It appears that it’s often easier for pregnant women and children to get CHIP coverage than it is for most people to get Medicaid, but the details on that will also likely vary state to state
How do you qualify for Medicaid?
Unfortunately, that’s a question that varies somewhat from state to state. Generally, “blue”(traditionally run by democrats) states often have an expanded Medicaid program, which covers most people with no alternative options for health care coverage whose households are at or below a certain income. “Red”(traditionally mostly run by Republican) states often have stricter rules and more limitations on coverage.
Financial eligibility is based upon household income as a percentage of the poverty level(so changes each time the national poverty level changes), but the percentage of the poverty level can be up to 400% in certain cases(in other words, 4x the poverty level).
People on Supplemental Security Income are automatically eligible for Medicaid coverage, no matter what state they live in. SSI is also an asset-based program.
If you aren’t on SSI, you need to check your state’s rules on eligibility. As I mentioned, children are covered through CHIP, but the process is generally the same.
Mandatory coverage is in place for people on SSI, low-income families, and qualified pregnant women and children. These are part of the federal rules of coverage.
Many states have also expanded Medicaid after the Affordable Care Act was passed, permitting individuals to get Medicaid coverage by being under certain(higher than previously) income levels.
My partner Al spent years covered through New Jersey’s expansion of the ACA, since as a single man it would have been much more difficult to get coverage prior to that.
Once upon a time, there was just Medicaid in every state, now referred to as Original Medicaid. If your state still has an Original Medicaid program, look into it as it may be your best option.
Original Medicaid will have its own list of Medicaid providers(doctors it works with) and its own formulary(what medication it covers). Those are the two things you will need to compare with your other options.
So far, the only other options I have seen in Medicaid are various Health Maintenance Organization(HMO) plans.
HMO’s are generally very limiting insurance programs(they only cover their preferred network of doctors and the medications on their formulary), so it’s important to compare them carefully if at all possible.
Whatever your options are, if you have doctors you like and trust, please check the plans for them, and/or call their office to ask what (if any) forms of Medicaid they accept.
If any of your preferred doctors are available to you, it makes sense to select that network and deal with whatever other issues it has – all HMOs will have limitations and frustrating aspects to them.
If you don’t have a preferred doctor or none of your preferred doctors are available through any of the HMO’s, look to see what might have the most options, or check the formularies to see what medications you take are covered.
Every plan will have a specified time period where you can change your plan. It’s usually once a year, for around 30-45 days.
While Medicare and all Affordable Care Act insurance, and most businesses’ insurance coverage has a selection period in the late fall, usually into December, and then starts the new/updated coverage in January, it appears that the states take that as a suggestion, not a rule.
If you are on Medicaid, please do a search of your state’s Medicaid program to find out when your “open enrollment” period is.
This is the only time you can change plans if you are unhappy with the coverage you have, and the time when information on your coverage options are most likely to be available.
Also, keep an eye on your mail – you may get a statement from Medicaid that it’s your open enrollment period(or that it’s approaching).
If you are concerned or dissatisfied with your coverage, please check on when you can change it immediately, because it’s possible you just missed it, or that it’s coming up soon.
I’m not guaranteeing one HMO will be spectacularly better or worse than another one, but sometimes there are programs only certain doctors or hospitals run that could really help you, and it’s only available if you change HMO’s.
On a similar note, if you have a doctor you really like and trust, you may want to follow them if their office changes plans for any reason.
Extra Help and dual-eligibility
If you are on Medicaid you are automatically enrolled in a federal program called “Extra Help”(creative, right?), which also reduces your medication costs and some other expenses.
Extra Help automatically is provided to all people on Medicaid.
People who are on SSI have a variety of work incentives to help them return to work, so if you are on SSI and wish to return to work, you will want to explore your options.
Also, if you are covered by both Medicare and Medicaid, you are considered dual-eligible, which comes with its own advantages.
Medicaid is primarily income-based insurance that most often covers low-income children and their families and people on SSI. The Affordable Care Act helped expand offered coverage in some states to include lower-income individuals and people with disabilities.
People on SSI are guaranteed Medicaid coverage wherever they live or move to, but that is one of the few categories that has that reassurance.
Medicaid rules and options vary by state, but in most states, there are a variety of HMO’s to choose from, and if you’re lucky, your state may still have Original Medicaid.
Every year, there is an opportunity to change your plan, but while that month or time period is consistent year after year, it is not consistent across state lines. While most insurance programs have open enrollment between October and December, Medicaid doesn’t always do so, and your open enrollment period could literally be any month(or so) of the year.
Medicaid also often gets support from a federal program called Extra Help, which also helps reduce your medical expenses, especially drug costs.