What Is Traditional Medicaid For Adults


Expansion Under The Affordable Care Act

Medicaid Defined: How Does the Program Work?

As of March 2022, 38 states and the District of Columbia have accepted the Affordable Care Act Medicaid extension 12 states have not. Among adults aged 18 to 64, states that expanded Medicaid had an uninsured rate of 7.3% in the first quarter of 2016, while non-expansion states had a 14.1% uninsured rate. Following a 2012 Supreme Court ruling, which held that states would not lose Medicaid funding if they did not expand Medicaid under ACA, several states rejected the option. Over half the national uninsured population lives in those states.

The Centers for Medicare and Medicaid Services estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9 to 10 million people had gained Medicaid coverage, mostly low-income adults. The Kaiser Family Foundation estimated in October 2015 that 3.1 million additional people were not covered in states that rejected the Medicaid expansion.

Studies of the impact of Medicaid expansion rejections calculated that up to 6.4 million people would have too much income for Medicaid but not qualify for exchange subsidies. Several states argued that they could not afford the 10% contribution in 2020. Some studies suggested that rejecting the expansion would cost more due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage,

What Is Texas Medicaid

Texas Medicaid encompasses a variety of programs to provide financial health care coverage to eligible individuals throughout the state. Providing coverage for families, individuals and older adults, Texas Medicaid strives to preserve the well-being of Texans by providing quality health care services that can be accessed within beneficiaries’ communities.

In Texas, there are five types of Medicaid coverage:

  • STAR
  • STAR Health
  • Traditional Medicaid

Each of the STAR programs provides managed care for recipients. While STAR, STAR Kids and STAR Health offer services for families, kids and pregnant women, STAR+PLUS features managed care for those aged 65 and older and individuals who are living with disabilities. Traditional Medicaid covers individuals who aren’t eligible for managed care.

Who Can Get Medicaid

Many people with low incomes would be unable to afford health insurance without government assistance. This is where Medicaid comes into play. The U.S. Department of Health and Human Services determines the federal poverty level every year, and these values are used to set the eligibility standards for Medicaid.

All states cover certain categories of people, including low-income families, children, pregnant women, the elderly, and people with disabilities. The federal government sets the standard, but individual states can choose to expand coverage beyond these limits, such as to all individuals below a certain income level. States can increase income thresholds to include more people. You can learn more information about what your state program covers on the Medicaid.gov website.

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Mental Health Parity Requirements Under Both Traditional Medicaid And Abp Plans

The federal mental health parity requirements, as established in the Public Health Service Act , generally mandate that, under a given insurance plan, coverage of mental health and addiction services should be on par with coverage of medical and surgical services in terms of the treatment limitations , financial requirements , in- and out-of-network covered benefits, and annual and lifetime dollar limits. Managed care plans under both traditional Medicaid and ABPs must comply with all federal mental health parity requirements. ABPs that are not managed care plans are only required to comply with federal requirements for parity in treatment limitations and financial requirements. These plans are deemed to comply with federal mental health parity requirements if they offer EPSDT to individuals under age 21, for which they are statutorily required to cover.24

Why Should You Sign Up For Medicaid

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Medicaid offers comprehensive coverage for low costs. If you qualify, Medicaid is an excellent way to provide your family health insurance protection.

The ACA made it easier for Americans to get Medicaid. There are also proposals on Capitol Hill to expand the program even further. A so-called Medicaid buy-in program could allow all or at least more Americans to sign up for the federal-state health insurance program.

Thats one of a multiple healthcare reform proposals being discussed by Congress. Whether a Medicaid buy-in happens will depend on political factors. However, for now, more Americans can still sign up for Medicaid and get comprehensive benefits for low costs.

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Medicaid Eligibility And Benefit Coverage

Historically, eligibility for Medicaid was subject to “categorical restrictions” that generally limited coverage to the elderly, persons with disabilities, members of families with dependent children, certain other pregnant women and children, among others. As of January 1, 2014, federal law allows states to expand Medicaid eligibility for citizens with income up to 133% of the federal poverty level who do not fit into these traditional categories. The Congressional Budget Office estimated that the coverage expansion provisions in the ACA would increase enrollment in both the Medicaid and the State Children’s Health Insurance Programs by about 7 million in CY2014, rising to 13 million by CY2024.3

To qualify for Medicaid, applicants must have income that meet financial requirements. These financial criteria are usually tied to specific percentages of the federal poverty level , and are sometimes based on certain cash assistance programs .4

For the medically needy subgroup, states may offer a more restrictive benefit package than is available to most categorically needy individuals. Such individuals include people who meet the main categorical restrictions described above but may have higher income. States electing the medically needy option must provide coverage to certain pregnant women and children under age 18.5

Table 1. Examples of Medicaid Benefits, by Eligibility Classification

Title XIX of the Social Security Act and related federal guidance.

Who Is Eligible For Medicaid

You may qualify for free or low-cost care through Medicaid based on income and family size.

In all states, Medicaid provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. In some states the program covers all low-income adults below a certain income level.

Even if you were told you didn’t qualify for Medicaid in the past, you may qualify under the new rules. You can see if you qualify for Medicaid 2 ways:

  • Visit your state’s Medicaid website. Use the drop-down menu at the top of this page to pick your state. You can apply right now and find out if you qualify. If you qualify, coverage can begin immediately.
  • Fill out an application in the Health Insurance Marketplace. When you finish the application, we’ll tell you which programs you and your family qualify for. If it looks like anyone is eligible for Medicaid and/or CHIP, we’ll let the state agency know so you can enroll.

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Traditional Medicare And Medicare Advantage Enrollees Report Similar Difficulties Accessing Care

Cost as a barrier to care. A similar share of beneficiaries in traditional Medicare and Medicare Advantage plans report problems obtaining needed health care.

High cost is among the most frequently reported reasons for not getting needed care, followed by exclusion of a service from coverage . Relatively small shares of enrollees with either type of coverage reported problems with finding a specialist.

People with mental health conditions. A higher percentage of beneficiaries with a mental health condition than without one reported difficulty obtaining needed health care . The proportion of beneficiaries with mental health conditions reporting access difficulties did not differ significantly by type of coverage.

Wait times. Wait times for hospital outpatient and physician office visits are similarly long for traditional Medicare and Medicare Advantage, averaging about three weeks for a hospital outpatient visit and over one month for a physician office appointment . Waits were similar among those with mental health conditions and other common conditions.

Satisfaction with care. Regardless of coverage type, overwhelming majorities of Medicare beneficiaries in both traditional Medicare and Medicare Advantage report satisfaction with care .

Medicaid Covers 1 In 5 Americans And Serves Diverse Populations

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Medicaid provides health and long-term care for millions of Americas poorest and most vulnerable people, acting as a high risk pool for the private insurance market. In FY 2017, Medicaid covered over 75 million low-income Americans. As of February 2019, 37 states have adopted the Medicaid expansion. Data as of FY 2017 show that 12.6 million were newly eligible in the expansion group. Children account for more than four in ten of all Medicaid enrollees, and the elderly and people with disabilities account for about one in four enrollees.

Medicaid plays an especially critical role for certain populations covering: nearly half of all births in the typical state 83% of poor children 48% of children with special health care needs and 45% of nonelderly adults with disabilities and more than six in ten nursing home residents. States can opt to provide Medicaid for children with significant disabilities in higher-income families to fill gaps in private health insurance and limit out-of-pocket financial burden. Medicaid also assists nearly 1 in 5 Medicare beneficiaries with their Medicare premiums and cost-sharing and provides many of them with benefits not covered by Medicare, especially long-term care .

Figure 4: Medicaid plays a key role for selected populations.

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Medicaid Coverage Has Evolved Over Time

Under the original 1965 Medicaid law, Medicaid eligibility was tied to cash assistance or federal Supplemental Security Income starting in 1972) for parents, children and the poor aged, blind and people with disabilites. States could opt to provide coverage at income levels above cash assistance. Over time, Congress expanded federal minimum requirements and provided new coverage options for states especially for children, pregnant women, and people with disabilities. Congress also required Medicaid to help pay for premiums and cost-sharing for low-income Medicare beneficiaries and allowed states to offer an option to buy-in to Medicaid for working individuals with disabilities. Other coverage milestones included severing the link between Medicaid eligibility and welfare in 1996 and enacting the Childrens Health Insurance Program in 1997 to cover low-income children above the cut-off for Medicaid with an enhanced federal match rate. Following these policy changes, for the first time states conducted outreach campaigns and simplified enrollment procedures to enroll eligible children in both Medicaid and CHIP. Expansions in Medicaid coverage of children marked the beginning of later reforms that recast Medicaid as an income-based health coverage program.

Figure 3: Medicaid has evolved over time to meet changing needs.

Chip And Children’s Medicaid Dental Services

Most children and teens with CHIP or Children’s Medicaid coverage get their dental services through a managed care dental plan. There are two dental plans to choose from.

Those with Medicaid who do not get their dental services through one of those two plans include:

  • People with Medicaid age 21 and older.
  • All people with Medicaid, regardless of their age, who live in facilities such as nursing homes, state supported living centers, or community-based Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions .
  • Children and young adults in the state’s foster care program who get their dental services through STAR Health.

CHIP and Children’s Medicaid Dental Plans

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Medicaid Is The Nations Public Health Insurance Program For People With Low Income

Medicaid is the nations public health insurance program for people with low income. The Medicaid program covers 1 in 5 Americans, including many with complex and costly needs for care. The program is the principal source of long-term care coverage for Americans. The vast majority of Medicaid enrollees lack access to other affordable health insurance. Medicaid covers a broad array of health services and limits enrollee out-of-pocket costs. Medicaid finances nearly a fifth of all personal health care spending in the U.S., providing significant financing for hospitals, community health centers, physicians, nursing homes, and jobs in the health care sector. Title XIX of the Social Security Act and a large body of federal regulations govern the program, defining federal Medicaid requirements and state options and authorities. The Centers for Medicare and Medicaid Services within the Department of Health and Human Services is responsible for implementing Medicaid .

Figure 1: Medicaid plays a central role in our health care system.

Medicaid Is Structured As A Federal

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Subject to federal standards, states administer Medicaid programs and have flexibility to determine covered populations, covered services, health care delivery models, and methods for paying physicians and hospitals. States can also obtain Section 1115 waivers to test and implement approaches that differ from what is required by federal statute but that the Secretary of HHS determines advance program objectives. Because of this flexibility, there is significant variation across state Medicaid programs.

The Medicaid entitlement is based on two guarantees: first, all Americans who meet Medicaid eligibility requirements are guaranteed coverage, and second, states are guaranteed federal matching dollars without a cap for qualified services provided to eligible enrollees. The match rate for most Medicaid enrollees is determined by a formula in the law that provides a match of at least 50% and provides a higher federal match rate for poorer states .

Figure 2: The basic foundations of Medicaid are related to the entitlement and the federal-state partnership.

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Children’s Health Insurance Program Health Plans

Children in CHIP get services through a medical plan in their area. Some CHIP plans also offer services to mothers who are pregnant. This is called CHIP perinatal coverage.

You can see how well some CHIP health plans perform by looking at the CHIP health plan report cards.

To learn more about CHIP, visit the CHIP and Children’s Medicaid website.

A Few Frequently Asked Questions About What Medicaid Covers

What coverage do pregnant women get under Medicaid?

Pregnant women are covered for all care related to the pregnancy, delivery and any complications that may take place during pregnancy and up to 60 days postpartum.

Pregnant women may also qualify for care that was received for their pregnancy before they applied and received Medicaid. Some states call this Presumptive Eligibility and it was put in place so that all women would start necessary prenatal care as early in pregnancy as possible. Pregnant women are usually given priority in determining Medicaid eligibility. Most offices try to qualify a pregnant woman within about 2-4 weeks.

Does Medicaid cover VSG?

Vertical sleeve gastrectomy, also known as VSG, is surgery to help with weight loss. Medicaid does not cover weight loss surgery in most cases. However, it is best to check with your state on an individual basis to confirm that they do not offer it as a benefit separate from mandatory federal benefits.

Does Medicaid cover dental services?

Medicaid pays for emergency and medically necessary dental work across the country. Medicaid also pays for comprehensive dental care in more than 30 states. However, others may only cover certain categories of treatments. Medicaid does cover dental services for all child enrollees as part of the Early and Periodic Screening, Diagnostic and Treatment benefit. Check with your state to see what your exact level of dental coverage is.

What does Medicaid cover for children?

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What Are The Four Parts Of Medicare

Part A

Covers all hospital costs like hospital stays, hospice care, nursing home care, and other inpatient services.

Part B

Covers outpatient medical costs like doctor visits, medical supplies, and preventative services like shots and screenings. You typically need to pay a premium for these services, which means you pay an out-of-pocket monthly fee. If you dont sign up for Plan B when youre first eligible, you can sign up at a later date. However, there will be a 10 percent increase in your premium for every 12 months you dont have Plan B.

Part C

This is where Medicare can get a little tricky. Part C allows you to have a health plan provided by a private company like Health Maintenance Organizations or Preferred Provider Organizations . This plan is called a Medicare Advantage Plan, and it covers all Part A and Part B costs . Part C plans can be cheaper than paying premiums for other Medicare plans, but it depends on the private company you choose to enroll with and their premiums, copayments, and other costs.

Part D

Covers prescription costs and is added on top of whatever other plans you enroll with.

Medicare is funded in part by a tax added to your paycheck as well as premiums paid by Medicare enrollees and funding from the government.

Traditional Benefits And Alternative Benefit Plans Under Medicaid

The Medicaid Waiver Program

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The Medicaid program, which served an estimated 56.7 million people in FY2012, finances the delivery of a wide variety of preventive, primary, and acute care services as well as long-term services and supports for certain low-income populations. Benefits are available to beneficiaries through two avenues: traditional coverage and alternative benefit plans .

The traditional Medicaid program covers a wide variety of mandatory services , and other services at state option to the majority of Medicaid beneficiaries across the United States. Within broad federal guidelines, states define the amount, duration, and scope of these benefits. Thus, even mandatory services are not identical from state to state.

With the enactment of the Patient Protection and Affordable Care Act in 2010 , benefit requirements have expanded under ABPs. At a minimum, these plans must cover essential health benefits . In addition, at state option, a new group of citizens with income up to 133% of the federal poverty level is eligible for Medicaid as of January 1, 2014. These individuals are required to receive ABPs rather than traditional Medicaid benefits .

This report outlines the major rules that govern and define both traditional Medicaid and ABPs. It also compares the similarities and differences between these two benefit package designs.

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