Medicaid was created by the Social Security Amendments of 1965 which added Title XIX to the Social Security Act. Each state administers its own Medicaid program while the federal Centers for Medicare and Medicaid Services (CMS) monitors the state-run programs and establishes requirements for service delivery, quality, funding, and eligibility standards.
The Medicaid Drug Rebate Program and the Health Insurance Premium Payment Program (HIPP) were created by the Omnibus Budget Reconciliation Act of 1990 (OBRA-90). This act helped to add Section 1927 to the Social Security Act of 1935 which became effective on January 1, 1991. This program was formed due to the costs that Medicaid programs were paying for outpatient drugs at their discounted prices.
The Omnibus Budget Reconciliation Act of 1993 (OBRA-93) amended Section 1927 of the Act as it brought changes to the Medicaid Drug Rebate Program, as well as requiring states to implement a Medicaid estate recovery program to sue the estate of decedents for medical care costs paid by Medicaid.
In 1997, the Balanced Budget Act of 1997 added the Children’s Health Insurance Program.
In 2010, the Patient Protection and Affordable Care Act expanded Medicaid eligibility starting in 2014; people with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.
Included in the Social Security program under Medicaid are dental services. These dental services are an optional service for adults above the age of 21; however, this service is a requirement for those eligible for Medicaid and below the age of 21. Minimum services include pain relief, restoration of teeth and maintenance for dental health. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a mandatory Medicaid program for children that aims to focus on prevention on early diagnosis and treatment of medical conditions. Oral screenings are not required for EPSDT recipients and they do not suffice as a direct dental referral. If a condition requiring treatment is discovered during an oral screening, the state is responsible for taking care of this service, regardless if it is covered on that particular Medicaid plan.
During the 1990s, many states received waivers from the federal government to create Medicaid managed care programs. Under managed care, Medicaid recipients are enrolled in a private health plan, which receives a fixed monthly premium from the state. The health plan is then responsible for providing for all or most of the recipient’s healthcare needs. Today, all but a few states use managed care to provide coverage to a significant proportion of Medicaid enrollees. Nationwide, roughly 60% of enrollees are enrolled in managed care plans. Core eligibility groups of poor children and parents are most likely to be enrolled in managed care, while the aged and disabled eligibility groups more often remain in traditional “fee for service” Medicaid.
Some states have incorporated the use of private companies to administer portions of their Medicaid benefits. These programs, typically referred to as Medicaid managed care, allow private insurance companies or health maintenance organizations to contract directly with a state Medicaid department at a fixed price per enrollee. The health plans then enroll eligible people into their programs and become responsible for assuring Medicaid benefits are delivered to beneficiaries.
Some states operate a program known as the Health Insurance Premium Payment Program (HIPP). This program allows a Medicaid recipient to have private health insurance paid for by Medicaid. As of 2008 relatively few states had premium assistance programs and enrollment was relatively low. Interest in this approach remained high, however.
Difference between Medicare & Medicaid
Medicare and Medicaid are two entirely different programs:
|Medicare is a government health insurance program for people over 65 and for those who are on Social Security disability.||Medicaid is funded jointly by the Federal Government and the individual states. Individuals must meet specific financial and “need for care” requirements in order to receive Medicaid benefits.|
|Medicare qualification is based on age and/or disability. Participation not subject to income, asset or “needs” test.||Medicaid qualification is based on “need for care” and financial need. Single (unmarried) individuals must be essentially broke (below $2,000 in most states). Rules allow certain strategies to protect assets from Medicaid.|
|Medicare provides coverage for hospitalization, doctors and other types of medical expenses. Medicare is a medical insurance program, and except for a limited short-term nursing home benefit, is not coverage for nursing home or other long-term care.||Medicaid provides benefits for long-term nursing home care, and, in many states, benefits for other types of long-term care.|
|In order to get Medicare coverage for a nursing home stay, you must be in an approved skilled nursing facility, have been in the hospital for at least three days prior to entering the facility, and to be deemed by Medicare to be medically benefiting from that skilled nursing. Custodial care is not covered. Technically, there is a maximum of 100 days of nursing home benefit. In actuality, the requirement about medically benefiting usually limits the benefit to a period of 10-20 days for rehabilitation.||Those individuals who meet the definition of “need for care,” as well as the financial requirements, can qualify under Medicaid for nursing home care (including custodial care). There is no maximum limit on the period of time that care can be provided.|
|Under no conditions does Medicare pay for assisted living, residential care facilities, and adult foster care.||In many states, Medicaid will provide care in assisted living, residential care and/or adult foster care facilities.|
|Except during the time you’re in the hospital, Medicare does not cover medications.||Medications are covered by Medicaid.|
|Medicare does have some benefit for home health but this is purely for medical reasons, not for caregivers to come in and attend to someone who needs help with personal needs on a long-term basis.||In many states, in-home care is provided with Medicaid to allow for caregivers to come into the home to provide care and help with personal needs and activities of daily living.|
Many groups of people are covered by Medicaid. Even within these groups, though, certain requirements must be met. These may include your age; whether you are pregnant, disabled, blind, or aged; your income and assets, and whether you are a U.S. citizen or a qualified alien. Non-qualified aliens or undocumented immigrants may be eligible for emergency assistance only.
When you apply for Medicaid, the requirements listed above will be taken into account before a decision is made.
If you or someone in your family needs health care, you should apply for Medicaid even if you are not sure whether you qualify or if you have been turned down in the past.
Basic Eligibility Criteria
You may be eligible for Medicaid if your income is low and you match one of the following descriptions:
- You think you are pregnant
- You are a child or teenager
- You are age 65 or older
- You are legally blind
- You have a disability
- You need nursing home care