Monitoring Substitution Of Coverage In Chip
States are required to include in their state plan a description of procedures used to ensure that CHIP coverage does not substitute for coverage under group health plans. States use various procedures to prevent substitution of coverage, such as monitoring survey data or private insurance databases, or applying a waiting period for individuals who are no longer enrolled in private coverage. This requirement can be found at section 2102 of the Social Security Act. Additional information on states specific CHIP waiting period policies.
Reduced Coverage / Medicare Cost Sharing Or Premium Payment
Qualified Medicare BeneficiariesCovered group: individuals covered by MedicareIncome limits: Income cannot exceed 100% of the federal poverty level. For more information, view the Guidelines for Medicare Cost-Sharing Programs brochure.Age: Medicare beneficiaries of any ageQualifications: Individuals must be eligible for Medicare Part A hospital insurance.
Specified Low-Income Medicare BeneficiariesCovered group: individuals covered by MedicareIncome limits: Income cannot exceed 135% of the federal poverty level. For more information, view the Guidelines for Medicare Cost-Sharing Programs brochure.Age: Medicare beneficiaries of any ageQualifications: Individuals must have Medicare Part A
Qualified IndividualsCovered group: individuals covered by MedicareIncome limits: Income cannot exceed 135% of the federal poverty level. For more information, view the Guidelines for Medicare Cost-Sharing Programs brochure.Age: Medicare beneficiaries of any ageQualifications: Individuals must have Medicare Part A
Policy Basics: Introduction To Medicaid
In 2018, Medicaid provided health coverage for 97 million low-income Americans.
In 2018, Medicaid provided health coverage for 97 million low-income Americans over the course of the year. In any given month, Medicaid served 32 million children, 28 million adults , 6 million seniors, and 9 million people with disabilities, according to Congressional Budget Office estimates.
Children account for more than two-fifths of Medicaid enrollees but only one-fifth of Medicaid spending. Only one-fifth of Medicaid enrollees are seniors or people with disabilities, but because they need more health care services, they account for nearly half of Medicaid spending.
Medicaid is sometimes confused with Medicare, the federally administered, federally funded health insurance program for people over 65 and some people with disabilities. And there is overlap between the two programs: nearly 10 million low-income seniors and people with disabilities so-called dual eligibles are enrolled in both Medicare and Medicaid.
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How To Apply For Ny Medicaid
You may apply for Medicaid in the following ways:
- Enrollment Assistors offer free personalized help.
- To speak with the Marketplace Customer Service Center call 355-5777
- Through a Managed Care Organization
- Call the Medicaid Helpline 541-2831
- Through your Local Department of Social Services Office
Where you apply for Medicaid will depend on your category of eligibility. Certain applicants may apply through NY State of Health while others may need to apply through their Local Department of Social Service . No matter where you start, representatives will help make sure you are able to apply in the correct location. For more information on determining your category of eligibility and where you should apply read on.
NY State of Health determines eligibility using Modified Adjusted Gross Income Rules. In general, income is counted with the same rules as the Internal Revenue Service with minor variations. Individuals who are part of the MAGI eligibility groups listed below should apply with NY State of Health.
- Adults 19-64 years of age and not eligible for Medicare,
- Children 1 – 18 years of age
- Pregnant Individuals,
- Parents and Caretaker Relatives of any age
Individuals who are part of the non-MAGI eligibility groups listed below should apply with their Local Department of Social Services .
Other factors that may affect your eligibility include:
- State Residency
- Family or Household size
Medicaid Application for Non-MAGI Eligibility Group
Supplement A
Q Who Qualifies For Medicaid
A. Citizenship and Residency – To obtain full Medicaid benefits in Delaware, you must be a Delaware resident and either a U.S. citizen or a legally residing noncitizen. Full coverage for noncitizens which include DACA recipients is dependent on the availability of state funding. However, noncitizens can qualify for coverage for emergencies and labor & delivery services if income requirements are met.
Income Level – Qualifying for Medicaid is also based on need. Household income must be under certain limits as defined by the Federal Poverty Level and is based on family size. For Long Term Care programs, financial resources must also be under a certain amount. There are also specific programs for individuals who meet certain medical or disability tests, or who qualify due to age or pregnancy. To find out more about different Medicaid and other medical assistance programs, visit DMMA Programs & Services.
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Medicaid Is Structured As A Federal
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.
How Much Will Medicaid Cost Me
It depends. Every state is different. You will probably not have to pay a monthly premium for Medicaid, but most people do have some out-of-pocket costs.2 Emergency services, family-planning services, pregnancy-related services and preventive care for children are all fully covered with no additional cost to you.
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Most Medicaid Enrollees Get Care Through Private Managed Care Plans
Over two-thirds of Medicaid beneficiaries are enrolled in private managed care plans that contract with states to provide comprehensive services, and others receive their care in the fee-for-service system . Managed care plans are responsible for ensuring access to Medicaid services through their networks of providers and are at financial risk for their costs. In the past, states limited managed care to children and families, but they are increasingly expanding managed care to individuals with complex needs. Close to half the states now cover long-term services and supports through risk-based managed care arrangements. Most states are engaged in a variety of delivery system and payment reforms to control costs and improve quality including implementation of patient-centered medical homes, better integration of physical and behavioral health care, and development of value-based purchasing approaches that tie Medicaid provider payments to health outcomes and other performance metrics. Community health centers are a key source of primary care, and safety-net hospitals, including public hospitals and academic medical centers, provide a lot of emergency and inpatient hospital care for Medicaid enrollees.
Figure 6: Over two-thirds of all Medicaid beneficiaries receive their care in comprehensive risk-based MCOs.
Q What Documents Will I Need To Provide When I Apply
A. You will need to provide verification of your income. You do not need to provide proof of your assets or resources or come into our offices to be interviewed unless you are applying for one of the Long Term Care Medicaid programs .
If you are pregnant, you will need to provide proof that you are pregnant. If you are not a U.S. citizen, you will need to provide proof of your alien status. For example, you can provide a copy of your green card.
If you apply online using ASSIST, a web page at the end of the application will tell you exactly what documents must be sent by mail to support the application you are submitting, and the appropriate mailing address.
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Q If I Dont Qualify For Medicaid Is There Any Other Help For Me Or My Children
A. Yes. Many organizations in Delaware are dedicated to the principle that health care should never be beyond the reach of those who need it. If you need health care, but do not have insurance coverage, the people at the Delaware HelpLine have a wealth of information about organizations that provide health care at reduced rates for uninsured individuals. Call the Delaware HelpLine toll-free at 1-800-464-HELP from Monday Friday from 8:00 a.m. to 5:00 p.m. The Delaware Helpline service is also available in Spanish. Additional information about the support provided by the Delaware Helpline can also be found by visiting www.delawarehelpline.org.
For example, you may qualify to receive discounted medical services through the Community Healthcare Access Program . CHAP helps connect uninsured individuals with affordable health care from primary care doctors, medical specialists, and other health providers including prescription programs, laboratory and radiology services. To find out more about this program, visit the website for the Community Healthcare Access Program, or call 1-800-996-9969 for eligibility guidelines.
You can read about CHAP and other healthcare resources for uninsured individuals in the Delaware Healthcare Resource Guide. This guide is also available in Spanish: Guía de Recursos de Salud.
Under 18:
Over 65:
Q How Long Will My Medicaid Benefits Remain Active
A. Medicaid is based on month to month eligibility. However, your benefits are redetermined on a yearly basis by DMMA to confirm whether you still remain eligible for the program you are receiving. Certain Medicaid programs require you to report changes in your situation within 10 days of the change. One example of a change that must be reported is new employment.
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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.
Appeals And Fair Hearings
Medicaid estate recovery is the process through which each state recovers the costs of medical services it has paid from the estate of the person who received those services. The Medicaid estate recovery program impacts two groups of people receiving Medicaid benefits:
- Anyone over the age of 55 who has received Medicaid assistance, and
- Anyone who is permanently institutionalized and has received Medicaid assistance, regardless of age.
The estate recovery program may collect money from the estate of a deceased Medicaid recipient as repayment for any medical care services that were provided to the recipient and paid for by Medicaid, while the recipient was over 55 years of age, or permanently institutionalized, regardless of age.
Medical care includes a wide range of services, including nursing home and community based in-home care services. It also includes any hospital and prescription drug services the participant received while in a nursing home, or while receiving in-home care. Medical care also includes capitation payments to Medicaid-contracted health insurance companies or medical providers administering a defined package of benefits. The federal government directs states to pursue Medicaid estate recovery for these services.
- During the lifetime of the surviving spouse, regardless of where he or she lives.
- From a surviving child who is under age 21 years or is blind or permanently disabled , regardless of where he or she lives.
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Q Can I Have Both Medicaid And Medicare At The Same Time
A. It depends. If you receive Supplemental Security Income from the Social Security Administration, you are automatically eligible for Medicaid and often receive Medicare as well. If you receive both Medicaid and Medicare, Medicaid will pay your Medicare premium, co-payments and deductibles. If you have both Medicare and Medicaid, you should show both cards to your medical care provider each time you receive services. Resources for Those Who Have Medicare and Full-Benefit Medicaid
Q Where Do I Go To Apply For Medicaid
A. There are several ways to apply for Medicaid and other medical assistance programs:
- On the internet, you can use ASSIST to check your eligibility for several different assistance programs by completing a self-screening questionnaire. ASSIST then allows you to apply online.
- You may also print an Application for Health Insurance/Medicaid. The application form is also available in Spanish/en Español.
- By phone, you can contact Medicaid Customer Relations at 1-800-372-2022 or 255-9500 to be directed to the Division of Social Services office closest to where you live. DSS staff members will help you find out more about eligibility for Medicaid and other assistance programs. Then the appropriate information and application forms will be mailed to you. Complete, sign and date the application form in ink and mail it to the address provided.
- For Long Term Care applications, please call the Long Term Care Medicaid Unit listed for the county where you live.
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Who’s Eligible For Medicaid
Medicaid beneficiaries generally must be residents of the state in which they are receiving Medicaid. They must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.
Q How Will I Receive My Medical Care
A. In Delaware, Medicaid benefits are provided mainly through a managed care organization, or MCO, under contract with the state. Managed care is an organized way to ensure that people receive the quality medical care they need in the most cost-effective manner. Some Medicaid recipients in Delaware those who also receive Medicare and those in Long Term Care Medicaid programs such as the Nursing Facility program do not receive their medical care through a managed care organization.
DMMA provides a choice of managed care organizations so you can select the MCO plan that is best for you and your family. Delaware contracts with two managed care plans AmeriHealth Caritas and Highmark Health Options.
The Medicaid MCO provides almost all of the care for Medicaid members who join their plan. Prescription and non-emergency medical transportation services are covered directly by Medicaid, not through the MCO. Medicaid recipients need to show their Medicaid card to pharmacies and transportation providers when receiving these services.
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What Can I Do If I Can’t Afford Health Insurance
8 Ways to Get Healthcare if You Can’t Afford Health Insurance
Lawfully Residing Targeted Low
States have the option to provide CHIP and Medicaid coverage to children and pregnant women who are lawfully residing in the United States and are otherwise eligible for coverage, including those within their first five years of having certain legal status. If states do not adopt this option, federal law requires a 5-year waiting period before many legal immigrants are permitted to enroll in Medicaid and CHIP. Learn more about providing health coverage to lawfully residing children and pregnant women at 2107 of the Social Security Act, and in SHO# 10-006 . A list of states providing Medicaid and CHIP coverage to lawfully residing children and/or pregnant women.
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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.
What Services Does Medicaid Cover
Medicaid covers more than 60 percent of all nursing home residents and roughly 50 percent of costs for long-term care services and supports.
Federal rules require state Medicaid programs to cover certain mandatory services, such as hospital and physician care, laboratory and X-ray services, home health services, and nursing facility services for adults. States are also required to provide a more comprehensive set of services, known as the Early and Periodic Screening, Diagnostic, and Treatment benefit, for children under age 21.
States can and all do cover certain additional services as well. All states cover prescription drugs, and most cover other common optional benefits include dental care, vision services, hearing aids, and personal care services for frail seniors and people with disabilities. These services, though considered optional because states are not required to provide them, are critical to meeting the health needs of Medicaid beneficiaries.
About three-quarters of all Medicaid spending on services pays for acute-care services such as hospital care, physician services, and prescription drugs the rest pays for nursing home and other long-term care services and supports. Medicaid covers more than 60 percent of all nursing home residents and roughly 50 percent of costs for long-term care services and supports.
How Much Does Medicaid Cost? How Is It Financed?
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