What you need to know about Medicaid. First, that it is funded by the US government but is run by each individual state. The states are given some very basic guidelines about who should be covered and which services must be offered, after that the states can make its own rules. This is why it seems as if there are different rules for each state – because there are. Since I am only familiar with rules in my state, Indiana, I will talk about Medicaid in my state.
In Indiana Medicaid is overseen by the states welfare department and covers low-income families on TANF (temporary assistance for needy families), pregnant women, the blind, aged and disabled, and children through the age of 21.
To qualify, each category of persons eligible, has its own set of eligibility requirements. It also limits what services are provided for each category.
Healthy adults under the age of 65 without children can’t get Medicaid at all.
Healthy adults with children under the age of 18 can get Medicaid if they are also eligible for the states welfare program (TANF). However, the income threshold for these families is extremely low – for a family of 2 they aren’t allow to make over $229.50 month. This category has comprehensive medical coverage which includes medical, vision, dental, prescription and limited transportation services.
Children up to the age of 21 are covered if they are on TANF or have their family’s income is below ( for a family of 2) $1650 without a premium charge or co-pay, (This category has comprehensive medical coverage which includes medical, vision, dental, prescription and limited transportation services as well.) $2200 with a small premium per month charge as well as co-pays.( This is the same comprehensive plan without transportation service)
Pregnant women whose income level matches those of families on Tanf receives comprehensive coverage. Pregnant women, who match income levels of children on the premium payment plan, get pregnancy only coverage which covers only those expenses directly related to their pregnancies.
People of all ages with disabilities can get comprehensive Medicaid if they meet both income eligibility guidelines as well as disability guidelines. It takes several months of medical review before this type of Medicaid is given.
The blind, disabled and aged who receive Medicare can qualify for a Medicaid program which covers the Medicare premium, deductible and copay. If they meet income guidelines.
For all programs there other standard eligibility rules besides income, but I’ll skip the details here.
All of these programs (except the last one) operate like an HMO. Each member selects a PMP (primary care physician) who is responsible for directing their care. Each member must receive services within their network unless they have special permission from their network or are receiving necessary emergency medical. care. Services ( including non-medically necessary emergency services) can be denied if their PMP didn’t authorize the service or if it is received out-of network. There are also limits about how times per year you can receive a service (like eye exams)for certain things. For adults in all programs there can be low co-pays for medicines.
Every member of the Medicaid program receives a Medicaid card. They present the card to receive care and the medical provider usually checks eligibility before performing service.
This is how the Medicaid system works in Indiana