Medicaid: Is It An Option For You?

Having health insurance is very important but at certain times in our lives the cost of health insurance may seem completely unfeasible. If your income is below a certain level, you may qualify for Medicaid. Medicaid can help to provide excellent insurance at a very low cost or even no cost dependent upon your circumstances. Even if Medicaid is not an option, there may be other financially feasible options for health insurance.  The process for enrollment can be a little confusing, so (as always) we recommend working with a licensed broker.  There is no additional fee when working with a broker, but they can help to make the process much less confusing.  If you need assistance, you can reach us at (888) 918-0518 or schedule a call today


What is Medicaid?

Medicaid is a program jointly funded by the federal government and individual states.  It helps to provide health coverage to millions of Americans including:

  • Eligible Low-Income Adults
  • Children
  • Pregnant Women
  • Elderly Adults
  • People with Disabilities

States have a certain control over the type, amount and duration of services offered, but these must meet Federal guidelines.  This means that there are certain mandatory benefits that must be offered, but states can choose to offer additional benefits.  Some of the mandatory federally regulated benefits for Medicaid are:

  • Inpatient and Outpatient Hospital Procedures
  • Preventative Services
  • Doctor’s Visits
  • Laboratory and X-Ray Services
  • Family Planning
  • And More

***For a full list of mandatory federally regulated benefits, check out medicaid.gov.

Additionally, states may choose to offer additional benefits such as:

  • Prescription Drugs
  • Dental 
  • Vision
  • Occupational Therapy
  • And More

Most likely, your provider will accept Medicaid (a little more than 70% of providers do).  However, if your provider does not, you’re going to want to find one that does.  If not, you may be responsible for 100% of the costs out of pocket.  Your state’s Medicaid office can assist you.  Additionally, you can logon to medicaid.gov to find more information about your state’s Medicaid program. 


Am I Eligible For Medicaid?

Eligibility is determined by a series of factors largely: income, household size and, of course, your state’s individual regulations. You are most likely eligible for some type of medicaid program if:

You make less than 100%-200% of the federal poverty level


Are pregnant, elderly, disabled or a parent/caretaker of a child.

***If you make less than 133% of the FPL, it’s possible there is still a program available for you, but it really depends on your state.  

Additionally, to be eligible for Medicaid, you must meet certain non-financial eligibility criteria. 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.

Medicaid moneyAlso, states have the option to establish a “medically needy program”.  This helps  individuals who would be disqualified for Medicaid based on their income, but who have significant health needs.   Medically needy individuals can still become eligible by “spending down”.  Individuals spend down by incurring expenses for medical care for which they do not have health insurance.  If your medical expenses are large enough, it may push your income down enough to make you eligible for Medicaid.  Luckily most states have adopted a medically needy program.   

Eligibility can be a tricky topic and it really does vary from state to state.  For this reason, you are going to want to contact your state’s Medicaid office or logon to medicaid.gov for additional resources.  


How Much Does It Cost?

Generally speaking there are no monthly premiums for Medicaid.  Usually, you will not have to pay out of pocket to keep your coverage.  However, if you are receiving social security benefits, a nominal amount may be deducted.  You may also be charged a copay for services.  These copays are determined by the state and are usually very low.  Additionally, there are services that have no copay regardless of your location.  Services such as:

  • Family Planning
  • Preventative Services
  • Emergency Services
  • Children’s Services

*** Pregnant women and children cannot be denied care based on their inability to pay a copay.  They are exempt from copays.  


Pregnancy & CHIP

If you are pregnant, you may be eligible for Medicaid.  This can help cover all of your Medicaid CHIPprenatal care needs.  Medicaid will cover:

  • Labor and delivery in a hospital or state recognized birth center
  • Nurse midwife services or nurse practitioner services
  • 60 days postpartum care 

Additionally, children may be covered through Medicaid or through the CHIP program.  CHIP covers children up to 19 years old with both medical and dental coverage.  In fact, most people participating in a Medicaid program are children.  With Medicaid, neither pregnant women nor children can be denied services and there are no copays. 


When Do I Enroll in Medicaid?

You can apply for Medicaid at any time.  There are no open enrollment periods.  If you need assistance, you should apply for Medicaid, even if you are unsure if you qualify.  There may be additional options available to you.  Also, if you are denied Medicaid, you may become eligible for a special enrollment period for insurance through the marketplace.  

To enroll in Medicaid you will need to either contact your state’s medicaid agency or fill out a form through healthcare.govTo complete your Medicaid application, you will likely need to provide documentation that you meet your state’s requirements. This documentation may include:

  • Your birth certificate or driver’s license to serve as proof of age and citizenship
  • Recent pay stubs or tax returns to serve as proof of income
  • Copies of bank statements
  • Proof of address, which could include a lease, utility bill statements or a copy of your mortgage
  • Medical records to serve as proof of disability

States have 45 days to process your Medicaid application. They have 90 days if eligibility is tied to a disability.  If you are denied, and you feel there has been an error, you can appeal.  Additionally, there may be other options.  Actually, some of these options will become available if and after you are denied Medicaid.  So, if you feel this is the option for you, we highly encourage you to apply.  


Medicaid & Medicare

If you are covered by Medicaid and Medicare you have what’s known as dual eligibility.  Yes; you can be eligible for both!  In order to have dual eligibility, you’ll need to meet your state’s Medicaid criteria plus medicare criteria.  There is some overlap, but on top of your state’s medicaid criteria you must:

  • Be over 65 AND
  • Be eligible for or receiving social security or railroad retirement benefits


  • Have received 24 months of disability benefits

If you have dual eligibility, you can enroll in a dual health planDual health plans are designed just for people who have both Medicaid and Medicare. They’re a special type of Medicare Part C (Medicare Advantage) plan. Dual health plans combine hospital, medical and prescription drug coverage. You’ll keep all your Medicaid benefits. Plus, you could get more benefits than with Original Medicare. And you could get it all for a $0 plan premium.  If you are interested in pursuing this option, we highly recommend contacting a broker for assistance. 

If you’d like our assistance, you can reach us at iHealthBrokers at (888) 918-0518 or schedule a call today. It’s very important to have coverage but it can all be quite overwhelming, so please feel free to give us a call or check out our youtube channel for more helpful videos!


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Jesse Smedley is the Principal Broker for iHealthBrokers and the founder, president, and CEO of Smedley Insurance Group, Inc. and iHealthBrokers.com. Since the inception of SIG in 2007, Jesse has been dedicated to helping people save money on their health insurance by providing them with resources to educate themselves on all their health insurance options, both under age 65 and Medicare beneficiaries. He is featured in many publications as well as writes regularly for expert columns regarding health insurance and Medicare.

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