The federal government requires the states to provide individuals in certain low-income or low-resource categories with Medicaid coverage. Coverage is available to people receiving TANF assistance; people eligible for TANF but not receiving assistance; people receiving foster care or adoption assistance under the Social Security Act; children under six years of age from low-income families; some people who lose cash assistance when their work income or Social Security benefits exceed allowable limits; pregnant women with low incomes; infants born to Medicaid- eligible pregnant women; people age sixtyfive and over or legally blind or totally disabled people who receive Supplemental Security Income (SSI); and certain low-income Medicare recipients. At times, federal programs and initiatives are enacted that give states the opportunity to expand Medicaid coverage in particular ways to targeted groups. Recent examples include the State Children’s Health Insurance Program (SCHIP), Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services for children under age twenty-one who are enrolled in Medicaid, the Ticket to Work and Work Incentives Improvement Act (TWWIIA) of 1999 for people with disabilities who want to work, and the New Freedom Initiative aimed at reducing barriers to full community integration for people with disabilities and long-term illnesses.
The Welfare Reform Act made it more difficult for certain groups to obtain coverage, including disabled children and immigrants.
Categorically needy individuals qualify for Medicaid based on their low income and lack of resources; medically needy people receive assistance from some states because they encounter high medical bills and have limited income and resources. Medically needy individuals may have incomes that exceed Medicaid limits.
When determining eligibility, states examine a person’s income, current assets (some assets are not counted), and assets that have recently been transferred into another person’s name.
Medicaid usually does not pay for services that are not medically necessary, procedures that are experimental or investigational, and cosmetic procedures.
States offer a variety of plans, including fee-forservice and managed care plans. The trend is to shift recipients from fee-for-service plans to managed care plans.
When a Medicaid recipient has coverage under another insurance plan, that plan is billed first. Once the remittance advice from the primary carrier has been received, Medicaid may be billed.
