Medicaid: What It Is, Who Qualifies, and How to Apply
Medicaid is a government health insurance program that helps eligible people receive health care and, in some cases, long-term services and supports that they might otherwise be unable to afford. It is jointly funded by the federal government and individual states, but each state administers its own Medicaid program.
This is important because Medicaid is not exactly the same in every state. Income limits, eligibility rules, covered services, program names, and application processes can vary depending on where you live.
In Massachusetts, the Medicaid program is known as MassHealth.
What Does Medicaid Cover?
The exact benefits depend on your state and the type of Medicaid coverage you qualify for. Coverage may include:
- Doctor and specialist visits
- Hospital care
- Prescription medications
- Laboratory tests and X-rays
- Behavioral health and substance use treatment
- Preventive care
- Transportation to certain medical appointments
- Home health services
- Personal care assistance
- Nursing home care
- Long-term services and supports
- Certain community-based programs that help people remain at home
For older adults and people with disabilities, Medicaid can be particularly important because it may help pay for long-term care and supportive services that Medicare generally does not cover on an ongoing basis.
Who Can Qualify for Medicaid?
There is no single income limit or eligibility rule that applies to everyone in the United States. Eligibility depends on your state and the Medicaid program or coverage category for which you are applying.
Factors that may be considered include:
- Income
- Age
- Household size
- State residency
- Citizenship or qualifying immigration status
- Disability
- Pregnancy
- Whether you are a parent or caregiver
- Need for long-term care
- Assets, for certain programs
Some Medicaid eligibility groups use income-based rules that generally do not include an asset test. Other programs—particularly those involving adults age 65 and older and certain long-term-care services—may have both income and asset requirements.
Because the rules vary, it is important not to assume that you make too much money or have too many assets to qualify. There may be different programs available depending on your circumstances.
Medicaid and Medicare Are Different
Medicare and Medicaid are often confused, but they are different programs.
Medicare is primarily a federal health insurance program for people age 65 and older and certain younger people with disabilities.
Medicaid is based on financial and other eligibility requirements and is administered by individual states.
Some people qualify for both Medicare and Medicaid. These individuals are often called “dual eligible.” Depending on the person’s eligibility, Medicaid may help with certain Medicare costs and provide services that Medicare does not fully cover.
Why Medicaid Can Be Important for Long-Term Care
One of the most important things to understand about Medicaid is its role in paying for long-term care.
Medicare generally does not pay for ongoing custodial care simply because someone needs help with everyday activities such as bathing, dressing, eating, or using the bathroom. Medicaid, however, may cover long-term services and supports for eligible individuals.
Depending on the state and program, these services may be provided in:
- A person’s own home
- A family member’s home
- A community-based setting
- An assisted living or supportive housing setting under certain programs
- A nursing facility
Some states also have programs that allow eligible individuals to receive services at home rather than moving into a nursing facility.
Can a Family Member Be Paid as a Caregiver?
In some circumstances, yes. Certain Medicaid-funded programs allow eligible individuals to receive care at home and may provide options for a family member or another person chosen by the individual to serve as a paid caregiver.
The rules vary considerably by state and program. Not every family member can be paid under every program, and eligibility may depend on the care recipient’s medical and functional needs.
If you are caring for a family member, it is worth asking your state’s Medicaid agency specifically about self-directed care, consumer-directed programs, personal care programs, and home- and community-based services.
How to Apply for Medicaid
Medicaid applications are handled at the state level. Depending on where you live, you may be able to apply:
- Online
- By telephone
- By mail
- In person
- With help from an enrollment counselor or community organization
You may be asked to provide information about your household, income, residency, and other circumstances. People applying for certain programs may also need to provide information about assets, health conditions, disabilities, or the need for long-term care.
Before applying, it can be helpful to gather documents such as identification, proof of income, Social Security information, health insurance information, and financial records if the program has an asset requirement.
Do not delay applying simply because you are unsure whether you qualify. The state Medicaid agency makes the official eligibility determination.
Common Barriers to Getting Medicaid
Although Medicaid provides critical assistance, the application process can sometimes be difficult to navigate.
Not knowing which program to apply for: Medicaid is not one single type of coverage. A person may qualify under one eligibility category but not another.
Assuming income is too high: People sometimes never apply because they believe they will not qualify. Different programs can have different financial rules.
Confusion about assets: Asset rules can be especially complicated for older adults and people seeking long-term-care coverage. Not every Medicaid program has the same asset requirements.
Complicated paperwork: Applications may require supporting documents, and missing information can delay a decision.
Not responding to requests for information: If the Medicaid agency asks for additional documentation and does not receive it by the deadline, an application or continued coverage may be affected.
Missing renewal notices: Medicaid coverage must be maintained according to program rules. Keeping your address, telephone number, and other contact information current can help ensure that you receive important notices.
Language, disability, and technology barriers: Online applications can be difficult for people who do not have reliable internet access or who need assistance because of language, vision, hearing, cognitive, or other accessibility needs. Applicants should ask their state Medicaid agency about available assistance and accommodations.
What If You Are Denied?
A denial does not necessarily mean that there are no options available.
If you receive a denial, read the notice carefully. It should explain why you were found ineligible and provide information about your rights. Depending on the circumstances, you may be able to:
- Provide missing or corrected information
- Ask for clarification about the decision
- Apply under another eligibility category
- Request an appeal or fair hearing
- Get help from a legal aid organization, benefits counselor, aging-services organization, or other community resource
Pay close attention to any deadlines listed in the notice.
Medicaid Planning and Long-Term Care
Medicaid eligibility can become especially complicated when someone needs nursing home care or extensive long-term services.
Rules involving assets, property, spouses, transfers of assets, and long-term-care eligibility can be complex. People should be cautious about giving away money or transferring property solely to become eligible for Medicaid without first understanding the rules.
For complicated financial or legal situations, consider speaking with a qualified elder-law attorney or knowledgeable benefits professional.
If You Live in Massachusetts
In Massachusetts, Medicaid is called MassHealth. MassHealth provides health coverage and assistance with health care costs for qualifying children, adults, families, older adults, and people with disabilities.
Eligibility can depend on factors including age, income, household composition, residency, assets in certain programs, and whether a person needs long-term-care services.
People age 65 and older and people applying for certain long-term-care services may have a different application and eligibility process than younger adults applying for standard health coverage.
A Good Rule to Remember
Do not rule yourself out before you apply or speak with someone who understands the program.
Medicaid is complicated, and eligibility rules vary not only from state to state but also from one Medicaid program to another. A person who does not qualify for one type of Medicaid coverage may qualify for another program or another form of assistance.
The best starting point is your state’s Medicaid agency, where you can learn about the programs available where you live and receive an official determination of eligibility.
This information is intended for general educational purposes and is not legal, financial, or benefits advice. Medicaid rules and eligibility requirements can change and vary by state. Always confirm current requirements with your state Medicaid agency.