By Grace Matelich, last updated August 8, 2022

Medicaid is the nation’s public health insurance program for low-income adults. It is a federal and state plan program that covers Americans who have costly and complicated care needs. The majority of people who enroll in Medicaid are unable to afford other forms of health insurance.

Medicaid programs must follow federal guidelines. The federal government pays a portion of the costs, but Medicaid is operated individually by each state. Coverage and costs may be different, depending on your state’s needs and economic goals. Each state may also have a different name for their managed care programs such as Medi-Cal in California or the Medical Assistance Program in Illinois. 

In all states, Medicaid covers some low-income individuals, low-income families, low-income children, low-income pregnant women, the elderly, and people with disabilities. Qualifications also depend on household size, family size and status, and other factors. Each state has a different set of requirements that must be met to qualify as Medicaid beneficiaries. 

While each state has different condition of eligibility requirements, generally each applicant must meet all of the state program requirements:

• Be a resident of the state you are applying to
• Your financial situation is considered low income
• Be a citizen of the United States

In some states, the Medicaid program has been expanded to cover all adults below certain income levels. Each state has the option to choose the income level a person must fall into in order to qualify. The expansion of the program allows individuals to qualify based on income alone without any other requirements. The current criteria in most states are based on your income level is 133% below the federal poverty level.

Each state has its own program, enrollment, and eligibility for Medicaid coverage. What is paid for by Medicaid depends on each individual state. Refer to medicaid.gov to check covered care in your state. The following are the basic benefits of Medicaid healthcare coverage for senior living that Medicaid must cover:

• The ability to pick your own Primary Care Provider (PCP)
• Preventative coverage is provided based on gender, age, and health
• Medication for little to no cost
• Extra care and services such as dental, eye, and immunizations
• Inpatient and outpatient hospital services are covered
• Physician services
• Laboratory and x-ray services
• Home care health services
• Nursing Facility services
• Transportation to medical care
• EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
• Mental Health personal care services such as addiction or recovery treatment services

Below are optional coverages that vary from state to state:

• Prescription Drugs
• Clinic services
• Physical therapy
• Occupational therapy
• Speech, hearing, and language disorder services
• Respiratory care long-term services
• Other diagnostic, screening, preventive, and rehabilitative services
• Podiatry services
• Optometry services
• Dental Plans
• Dentures
• Prosthetics
• Eyeglasses
• Chiropractic services
• Other practitioner services
• Private duty nursing services
• Personal Care
• Hospice
• Case management
• Services for Individuals Age 65 or Older in an Institution for Mental Disease (IMD)
• Services in an intermediate care facility for Individuals with Intellectual Disability
• TB Related Services
• Health Homes for Enrollees with Chronic Conditions – Section 1945

The Medicaid waiver program is a federal government plan that allows each state to waive rules that usually apply to Medicaid. These waivers allow individuals that would otherwise not be covered by Medicaid, such as the elderly or pregnant women, to receive care. The Medicaid waiver can also allow seniors to receive care at home instead of a long-term care facility.  

After you find out if you are eligible for coverage there are usually no monthly payments, co-pay, or deductibles. If there are charges they are usually very small. 

The program pays almost the full amount for health and long-term services, provided the medical service supplier is Medicaid-certified.

States can charge premiums and impose cost sharing requirements for Medicaid enrollees. Out of pocket costs may include copayments, coinsurance or deductibles that are set by state law in accordance with certain guidelines; maximum out-of -pocket expenses vary based on the type coverage purchased (elders/disabled), income level etc., but states always exempt vulnerable groups like children & pregnant women from higher charges if they qualify under certain criteria such as low incomes.

Dementia and Alzheimer’s patients that live in assisted living are referred to as living in “memory care.” Medicaid by law can not pay for room and board but will cover the cost of care for Medicaid recipients.. In most memory care facilities, the Medicaid waiver can be used for the cost of room and board.

Similar to Medicare, Medicaid will not pay for the cost of living in an assisted living community. The Medicaid program will cover certain assisted living services. Currently, the following services are covered for qualified seniors:

• Nursing Care
• Case management
• Medication management
• Assessments
• Medical exams

Medicare is a federal program that is run by the federal government. It mainly focuses on and provides coverage to individuals who are 65+ or have a disability, no matter what their income. 

Medicaid is an assistance program run by both state and federal governments and provides health coverage if you have a very low income. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Eligibility is largely determined by income level. Medicaid programs offer a wider range of health care medical services compared to Medicare. 

You can qualify to have both Medicare and Medicaid at the same time. If you qualify for Medicare because you are 65 or older and you meet your state’s requirements for Medicaid you are considered “dual eligible.” You may be able to qualify for a dual eligibility plan if:

• You qualify for Medicaid in your state
• You qualify for Medicare Parts A and B (Original Medicare)
• You live in the dual-eligible plan’s coverage area

When you are qualified for both Medicare and Medicaid you are put into a dual health plan. This plan is a special type of Medicare Part C. Dual health plans combine medical, prescription, and hospital coverage while still keeping all of your Medicaid benefits. 

Dual health plans are offered by private insurance companies that allow you to pick the right coverage for you and your health care coverage needs. Medicaid may also pay some of the Medicare premiums, copayments, and deductibles for people who are enrolled in both programs.

Here are some important things to know about applying for Medicaid: 

CHIP is Medicaid for children. The Children's Health Insurance Program (CHIP) is for children whose parents do not qualify for Medicaid. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

You may qualify even if you did not before. Since needs and income can change you may qualify now for CHIP or Medicaid when you did not before. You can apply any time of year and if you qualify your coverage can start right away. 

Fill out an electronic or paper application through the Health Insurance Marketplace. If anyone from your household is “eligible,” the Health Insurance Marketplace will send your personal information to your state agency. Your state agency will then contact you about enrollment. 

Apply directly to your state Medicaid agency. Once you input your state on the site it will direct you to your Medicaid agency’s contact information.

Contact the Centers for Medicare & Medicaid Services. The Centers for Medicare & Medicaid Services (CMS) is part of the Department of Health and Human Services (HHS). The organization is there to help people to apply for Medicare, Medicaid/CHIP or enter the Marketplace to build their health care plans around the Affordable Care Act (ACA). The ACA makes it possible for affordable health insurance to become available to more individuals. 

Older adults and those with serious chronic medical conditions are considered to be at higher risk for contracting the virus. While the number of cases skyrocketed in 2020 it was important to protect our seniors from getting COVID-19. The following changes were made to Medicaid in response to the virus:

• Federally Enhanced Funding — States meeting certain criteria are able to access funding to help people obtain and maintain coverage.
• Telehealth Services — Telehealth services are medical or health services that generally occur in person. These services can now be performed by a doctor or other health care professional that is located elsewhere. The visits can be done via telephone or video. Due to the pandemic, some states expanded their services to include telehealth visits. This includes doctor visits and behavioral health counseling.
• Prescription Drugs  — During the pandemic, several states adopted a pharmacy cost-containment strategy to keep prices down. Several states are continuing to implement prescription drug cost containment.

Plans may have changed since the emergency first started. Applicants should contact their state agency directly to learn about which services are covered due to Coronavirus and those that are not.