Medicaid is a program operated by each state individually and partially funded by the federal government to provide health coverage for certain people with low incomes, as well as those with disabilities. In some cases, benefits may overlap with those of Medicare, which is fully funded and administered by the federal government.
Federal law requires state Medicaid programs to cover certain groups of individuals, including those receiving Supplemental Security Income (SSI), low-income families, as well as qualified pregnant women and children. Of the total 73 million people enrolled in Medicaid, more than 10 million people qualify due to a disability, almost half of whom are children born with disabilities.
Medicaid beneficiaries enrolled through disability pathways include those with:
- Physical conditions, such as quadriplegia, traumatic brain injuries
- Intellectual or developmental disabilities, such as cerebral palsy, autism, Down syndrome
- Serious behavioral disorders or mental illness, such as schizophrenia or bipolar disorder)
As Medicaid programs are operated on a state level, certain benefits can be different depending on where you live, particularly since some states expanded Medicaid under provisions of the Affordable Care Act (ACA), while others did not.
“As several states implemented, adopted, or continued to debate the ACA Medicaid expansion, a number of states also continued to pursue work requirements and other policies promoted by the Trump administration that could restrict eligibility,” the Kaiser Family Foundation reports.
Every state’s Medicaid program is required to provide some mandatory benefits, including:
- Inpatient hospital care
- Inpatient short-term skilled nursing or rehabilitation facility care
- Doctor services
- Outpatient hospital or clinic care
- Laboratory and X-ray services
- Short-term home health care (provided by a home health care agency)
- Transportation to medical care
Each state can decide whether to offer additional benefits, according to Caring.com, such as:
- Eye examinations and glasses
- Hearing tests and hearing aids
- Dental care
- Preventive screenings
- Physical therapy (beyond what is offered under Medicare)
- Non-emergency transportation to and from medical treatment
- Some prescription drugs not covered by Medicare
- Some nonprescription drugs, including certain vitamins
- Chiropractic care
Medicaid benefits for children include early and periodic screening, diagnostic and treatment as well as physical and behavioral health services. Children in families with incomes too high to qualify for Medicaid, but too low to afford private insurance, may receive benefits from the Children's Health Insurance Program (CHIP), which also may vary from state to state.
In most states, but not all, people who are approved for SSI are automatically approved for Medicaid benefits. In 32 states and the District of Columbia, the SSI application also serves as the Medicare application; in other states, some use the same eligibility criteria but require their own application form, while others have their own eligibility rules.
It is easy to confuse Medicaid with Medicare, and some 12 million people are considered “dual eligible” to receive benefits under both. But the programs are different. Medicare is available to all over 65, as well as younger individuals who meet disability requirements, with consistent benefits across all states.
Generally, people with disabilities who are approved for Social Security disability insurance (SSDI) benefits will qualify for the Medicare program but may have to wait as long as 24 months after their data of entitlement before being able to access Medicare benefits.
If you qualify for both Medicare and Medicaid, Medicare pays first for the Medicare-covered services that are also covered by Medicaid while Medicaid covers services that Medicare does not cover.
Because of overlaps with other programs, different application processes, and complexity of eligibility and benefits provisions, it’s a good idea to seek out Medicaid advice from the appropriate state and federal agencies as well as advocacy groups and even legal counsel. Individuals must have the ability to “request a fair hearing" regarding a denial, an action taken by the state agency that he or she believes was erroneous, or if the state has not acted with reasonable promptness,” says Medicaid.gov.
Resources:
Medicaid and Persons with Disabilities
A Beginner’s Guide to Medicaid
What is Medicare Dual Eligible and How Do I Qualify?
Contact Your State With Questions
Social Security: Disability Benefits
HHS: Who is eligible for Medicare?
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